Inspection·September 13, 2018

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and staff interview, the facility failed to complete a comprehensive care plan for one (#64) of 20 resident care plans reviewed during the investigation phase of the survey. The total facility census was 69. Findings Include: Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including after care for joint replacement, disease of the spinal cord, osteomyelitis, pain in the left hip, abnormalities of gait and mobility, fracture of unspecified part of the neck of the left femur, gastro esophageal reflux disease, personal history of methicillin-resistant staphylococcus aureus, pressure ulcer stage four to the right heel, weakness, hypertension, anemia, history of falling, diabetes, and major depression. Review of Resident #64 physician orders revealed the resident had orders for and was receiving since admission levofloxacin (antibiotic) 500 milligrams (mg) daily, with no stop date. Review of most recent admission Quarterly Minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview of mental status score of 15 indicating the resident was cognitively intact. Review of Resident #64 progress notes revealed the resident had a history of osteomyelitis of the spine and had been receiving levofloxacin since June 2018. Review of the residents care plans revealed the resident had a care plan indicating the resident was at risk for infection, however, the care plan was silent to the resident receiving a daily dose of antibiotic related to his history of wound infection. Interview with Resident #64 on 09/12/18 at 1:56 P.M. revealed he was taking the daily dose of antibiotics for his spine which he had an infection after surgery in 2013 and the infectious disease physician ordered daily antibiotic dose for life. Interview with Licensed Practical Nurse (LPN) #285 on 09/12/18 at 2:00 P.M., confirmed Resident #64 had levofloxacin daily as he had a history of an infection and the nurse stated he was to take it daily for life. Interview with Registered Nurse (RN) #309 on 09/13/18 at 12:10 P.M., confirmed Resident #64 takes a daily dose of levofloxacin 500 mg daily, and there was no care plan for resident concerning the long term use of his antibiotic therapy. Review of the policy titled Comprehensive Care Plan Guide dated 05/22/18 revealed interventions should be reflective of risk area(s) or disease processed that impact the individual resident. A comprehensive care plan will be developed within seven days of completion of the admission comprehensive assessment (MDS 3.0). Problem areas should identify the relative concerns, goals should be measurable and attainable, interventions should be reflective of the individual's needs and risk influence as well as the resident's strengths. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and staff interview, the facility failed to timely revise the care plan for one (Resident #9) of 20 residents reviewed in the investigation phase of the survey. The total facility census was 69. Findings include: Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, dysphasia, osteoporosis, Alzheimer's disease, chronic obstructive pulmonary disease, constipation, vitamin D deficiency, hypokalemia, generalized edema, dementia, difficulty in walking, symbolic dysfunctions, falls, osteoarthritis, hypertension, Parkinson's disease, pain, weakness, anxiety, atrial fibrillation, hypothyroidism, low back pain, and osteopenia. Review of the minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview of mental status score of seven indicating the resident had cognitive impairment. The resident required extensive assistance with activities of daily living with the exception of eating which required supervision. The resident was not on a toileting program but was incontinent of both bowel and bladder. The resident was assessed as having one unstageable pressure ulcer that measured 0.3 (centimeters) cm by (x) 0.3 cm that had slough in the wound bed. The resident was indicated to be receiving wound care and receiving hospice services. Review of care plans revealed the resident had a pressure ulcer to the right ankle. Review of Resident #9's progress notes revealed the resident's pressure ulcer to the right ankle was resolved with no open area on the right ankle dated 07/31/18. Review of Resident #9's physician orders revealed the resident had a new order written on 07/31/18 to place an ABD pad over right ankle bone and wrap for prevention every three days. Interview with the Director of Nursing (DON) on 09/12/18 at 7:45 A.M., confirmed Resident #9 does not have a pressure ulcer, the DON stated the resident formerly had a wound to her ankle and now had a preventative treatment to the area. The DON confirmed the area to the right ankle had not been opened for many months. Interview with the DON on 09/12/18 at 11:11 A.M., verified the care plan for Resident #9 was not current and still reflected the resident as having a pressure ulcer to her right ankle. The DON confirmed the care plan did not reflect the resident's current status and care needs as the right ankle ulcer had resolved in July. Review of the policy titled comprehensive care plan guideline dated 05/22/18 revealed comprehensive care plans need to remain accurate and current. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident was transferred safely and per physician's order to prevent a fall. This affected one (Resident #47) of three residents reviewed for accident hazards. The facility census was 69. Findings include: Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses that included intracranial injury, difficulty in walking, chronic pain, pain in right shoulder, repeated falls, muscle weakness, age related osteoporosis, dementia without behavioral disturbances, and hemiplegia affecting the right dominant side. Review of the quarterly minimum data set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) of 13. Further review revealed Resident #47 required extensive staff assist of two for transfers and toileting. Review of physician's order, dated 07/19/18, revealed Resident #47 was to be transferred using a stand up lift per lift assessment. Review of Resident #47's care tracker profile, for dates 04/25/18 through 09/11/18, instructed the State Tested Nurse Aides (STNA) to use a stand up lift for all transfers. Review of lift evaluation, dated 07/16/18, revealed Resident #47 was not ambulatory and could not reliably stand and pivot with only supervision or cueing. Further review revealed Resident #47 could follow simple instructions, was cooperative, could bear weight on at least one leg, could tolerate pressure to the mid back, and could maintain a sitting position without assistance. The stand up lift was recommended based on the assessment. Review of Resident #47's care plan, revised 07/19/18, revealed interventions to use the stand up lift for all transfers. Further review revealed the resident was at risk for falling due to decreased mobility, incontinence, and hemiparesis. Review of the progress note, dated 08/26/18, revealed an STNA was in the restroom with Resident #47 transferring her from the toilet to the wheelchair. The STNA lowered the resident to the floor. No injuries were noted. Review of the fall event, dated 08/26/18, revealed a gait belt as the only safety equipment used during the fall. Interview on 09/11/18 at 3:43 P.M. with the Director of Nursing (DON) confirmed a stand up lift was not used to transfer Resident #47 on 08/26/18 which resulted in a fall. Further interview confirmed the stand up lift should have been used per physician's order and care plan. Review of the facility policy titled Guidelines for Resident Transfers and Assistance, reviewed 05/23/18, revealed the purpose was to ensure the safety of residents and staff when performing mobility/transfer tasks. A Resident Lift Evaluation Profile algorithm was available to assistance with determining the type of lift most appropriate for the individual. Transfer evaluations would be ongoing quarterly by nurse and changes would need to be made to the care plans. All devices are safe to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm used by one staff member per manufactures guidelines. Staff should seek the assistance of a second person for those residents' care planned for assistance of two with the lifting device or as needed for safe handling. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of policy, the facility failed to properly store medications. This affected two (Resident #39 and #64) of 22 residents residing on the memory care unit. In addition, this affected one medication cart of two medication carts reviewed. The facility identified four medication carts. The facility census was 69. Findings include: 1. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, hypertension, muscle weakness, and major depressive disorder. Review of the physician's order dated 11/10/16 revealed Resident #39 was to have Bimatoprost (eye drops) 0.03% to bilateral eyes at bedtime. Observation on 09/13/18 at 10:10 A.M. of the medication cart on the memory care unit revealed two bottles of Bimatoprost eye drops for Resident #39. One bottle was opened and undated. The other bottle was opened and had the date of 07/19/18 as the date of opened. Interview on 09/13/18 at 10:30 A.M. with Licensed Practical Nurse (LPN) #285 confirmed the observation. Further interview confirmed eye drops, once opened, expire after 28 days. 2. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus with diabetic neuropathy, hypertension, and major depressive disorder. Review of the physician's order dated 08/11/18 revealed Humalog (insulin) 100 unit/milliliters per sliding scale to be administered before meals and at bedtime. The Humalog was discontinued on 08/17/18. Observation on 09/13/18 at 10:10 A.M. of the medication cart on the memory care unit revealed two vials of Humalog insulin for Resident #64. One vial was opened and dated 08/12/18, the other vial was opened and dated as 08/13/18 when opened. Interview on 09/13/18 at 10:30 A.M. with LPN #285 confirmed the observation. Further interview confirmed insulin vials, once opened, expire after 28 days. 3. Observation on 09/13/18 at 10:10 A.M. of the medication cart on the memory care unit revealed 14 unidentified loose pills in the second drawer, 10 unidentified loose pills in the third drawer, and 19 unidentified loose pills in the bottom drawer of the cart totaling 43 loose pills. Interview on 09/13/18 at 10:30 A.M. with LPN #285 confirmed the observation. Review of the facility policy titled Medication Storage in the Facility, (revised January 2017) revealed medications and biologicals are stored safely, securely, and properly, following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm manufacturer's recommendations or those of the supplier. Medication storage areas are kept clean. Certain medications or package types, such as intravenous solutions, multiple dose vials, ophthalmic's, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of recipe and policy review the facility failed to keep fortified milkshakes at a 41 degree temperature or lower prior to serving. The facility identified seven Residents (#4, #9, #16, #19, #59, #122, #272) who received fortified milkshakes. The facility census was 69. Residents Affected - Few Findings include: Observation on 09/13/18 from 12:02 P.M. to 12:35 P.M., of the lunch service line revealed six fortified milkshakes sitting on the counter, three strawberry flavored and three chocolate flavored. The milkshakes were for six residents in the main dining room. At 12:25 P.M. the milkshakes were still on the counter. Dietary Manager (DM) #116 stated they were to be served and took the temperature of two of the milkshakes. The chocolate milkshake was 44 degrees Fahrenheit (F) and the strawberry milkshake was 48 degrees F. DM #116 confirmed the milkshakes should have been in the refrigerator or put on ice to maintain a temperature of 41 degrees F or below until served. Review of the recipe for Fortified Shakes revealed the shakes consisted of the dairy product evaporated milk and whole milk. The recipe indicated to combine milk, evaporated milk and milkshake flavor mix together and refrigerate at 41 F degrees or below until serving. Review of the Policies and Procedures for Refrigerated Storage revealed refrigerated storage temperatures will be at 41 degrees F or below. Prepared perishables such as salads, puddings, milk, etc., are stored in a refrigerator and covered labeled and dated until used. Review of the Food Temp Serving Line Policy and Procedures (03/30/18) revealed cold foods are maintained and served at 41 degrees Fahrenheit or less for all TCF food items. Temperatures are taken prior to service to ensure all hot foods and cold foods holding temperatures are maintained at the proper temperatures. Review of a list of residents who received Fortified milkshakes revealed seven Residents (#4, #9, #16, #19, #59, #122, #272) who received fortified milk shakes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2. During an observation on 09/10/18 at 12:13 P.M. of the dining service in the locked unit of the lunch meal revealed dietary staff serving the meal from the steam table. The meal was lasagna, salad and garlic toast. The alternate included grilled cheese and chicken noodle soup. During the meal service the lasagna had a serving spatula, the salad had a serving ladle, chicken noodle soup had a serving ladle, however there was no serving utensil for the garlic toast or grilled cheese. When the tray line was started for the lunch meal Dietary Worker #252 was the only worker who was serving the meal. The worker was observed wearing gloves and would pick up the meal tray tickets, sort through the tickets and get the desired ticket, then proceed to plate the meal items. The worker plated the lasagna with the spatula, the salad with the ladle, and the garlic toast with her gloved hand. The dietary worker handed the tray to the staff delivering the tray to the resident and then picked up the next meal ticket and started the process again of plating the food each time touching the garlic toast with her gloved hand. If a resident requested the alternate of grilled cheese the dietary worker put the sandwich on the plate with her gloved hand as well. During the meal service, it was observed a staff member approached the dietary worker and requested creamer for a resident's coffee. Dietary Worker #252 was observed to reach below the steam table and with her gloved hand grabbed two creamers and handed them to the staff who had requested them. The dietary worker also obtained juice from the refrigerator with her gloved hands then proceed to serve the next meal. She touched the garlic toast with the same gloved hand. When the dietary worker served the alternate chicken noodle soup the worker reached below the steam table and obtained cracker packages with her gloved hands and placed them on the resident's tray. During the lunch observation the dietary worker was not observed changing her gloves at any time during the observation. During an interview with Registered Nurse (RN) #120 on 09/10/18 at 12:31 P.M. it was confirmed Dietary Worker #252 was touching non clean items with her gloved hands and then touching food items causing cross contamination of the food items that were being served to the residents. RN #120 was observed speaking with the dietary worker regarding the observation. Review of the policy titled Single -Use Gloves with a date of 11/22/17 revealed to change gloves whenever an activity or work station change occurs or whenever they become contaminated, after touching equipment such as refrigerator doors or utensils that have not been cleaned and sanitized, after contacting chemicals, after interruptions in food preparation occur such as when answering the telephone, or checking in a delivery. Based on observation, staff interviews and policy review, the facility failed to maintain a clean sanitary kitchen. This had the potential to affect all the residents in the facility. The facility census was 69. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 1. Observation on 09/10/18 from 8:36 A.M. to 9:09 A.M. during tour of the kitchen revealed the following: Level of Harm - Minimal harm or potential for actual harm A. A case of bananas with a broom handle inside the box sitting on a milk crate. Dietary Employee (DE) #512 removed the broom handle and several gnat like insects were exposed on the inside and outside of the box and flying in the air. Residents Affected - Many B. The staging area from the main dining room revealed a cluster of boxes, and on the floor was a milk crate with wet dirty towels in it. In the same area there was a two compartment sink with a large dirty baking sheet in it. The baking sheet had an orange grease like substance on it with nit like insects on and around it. C. Above the ice cream freezer there were shelves with a dust like substance covering them. Beside the freezer there was a counter area covered with crumbs and dried food substances. D. Two stand alone refrigerators revealed dirty exterior doors, with dried food like substances on them. The interior walls contained splatters of milk and dried liquid substance. A visual inspection of the interiors of the refrigerators revealed the bottom of the refrigerators had several particles of food like substances and stains. Interview on 09/10/18,immediately following the observations with [NAME] #318 confirmed the above findings. Review of the Stored Food and Supplies Policy and Procedures revealed refrigeration equipment is routinely cleaned and defrosted and free from garbage and other waste. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During observation of the facility laundry room on 09/13/18 at 11:00 A.M. it was observed a rack of hanging clothes in the soiled side of the laundry room where the laundry sorting occurred. The rack of clothing has a sign on it that indicated, Looking for my home or a new home. The observations also revealed, the room where the washing machines were located was the same room where the dryers were located. The washing machines and dryers were on opposite walls and were approximately 10.5 feet away from each other. Around the outside wall of the room where the washing machines and dryers were located it was noted there were hooks on the wall that had mechanical lift slings hung from them. The slings were around the entire outside perimeter wall that extended from the washing machine to the dryers. Residents Affected - Some During an interview with Environmental Service worker #101 on 09/13/18 at 11:05 P.M. it was verified the rack of clothing in the soiled side of the laundry was clean clothing. Environmental Service worker #101 stated the clothes were clothes that had no resident's name in them and the staff tried to identify who they belonged to in order to return the clothes to the owner. If the the owner could not be located the clothes were used for residents who did not have clothes. Environmental Service worker #101 verified the clothing rack was always stored on the dirty side of the laundry. She indicated she felt that the clothing rack should not be stored there as the clothes were clean. Environmental Service Worker #101 revealed the lift slings were on the hooks by the washers. She stated when the slings come out of the wash they were to hang dry and that was where the laundry staff hung them to dry. She confirmed the slings were hung up right next to the washing machines where soiled clothes were placed in the machine. Environmental Service worker #101 did not indicate where, in the washing machine/dryer room the clean or dirty side division line of the room was. During an interview with the Director of Nursing (DON) on 09/13/18 at 11:41 A.M. it was verified the lift slings were always hung on the hooks that were by the washing machines to air dry. The DON also stated the facility did not have a policy concerning laundry storage. The DON stated she was not aware the rack of clothes that were not labeled were stored on the soiled side of the laundry, however she stated that it should not be stored with soiled clothing. Based on medical record review, observation, staff interview, and review of policy the facility failed to ensure personal protective equipment (PPE) was used when changing Resident #272's wound dressing identified as having methicillin-resistant staphylococcus aureus (MRSA). This affected one (Resident #272) of one resident reviewed for transmission based precautions. In addition, the facility failed to store clean lost items and clean mechanical lift pads according to standards of practice. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #272 was admitted to the facility on [DATE] with diagnoses that included bilateral primary osteoarthritis, hypertension, heart failure, and stage III pressure ulcer of sacrum. The minimum data set (MDS) was not due to be completed. Review of the physician order dated 09/06/18 revealed Resident #272 was to be in contact isolation for MRSA in wounds. Observation on 09/13/18 at 1:15 P.M. of Resident #272's room revealed a sign that indicated see the nurse before entering and a container with PPE including yellow gowns. Licensed Practical Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (LPN) #104 was observed to change Resident #272's dressing, a red biohazard bag was observed on the residents bed. After washing his hands and donning gloves LPN #104 removed Resident #272's dressing from his sacrum. The dressing had a moderate amount of yellow and green drainage. LPN #104 washed his hands and donned new gloves. Resident #272 had three wounds to his coccyx the largest measuring 1.3 centimeters (cm) length by 1 cm width by 1.1 cm depth. There was 0.8 cm undermining at noon and 2.7 cm undermining at six. While measuring the wounds, LPN #104 kneeled beside the bed with his shirt and forearms against the mattress. LPN #104 completed the dressing change by washing his hands, donning new gloves, and applying the new dressing per physician's order. LPN #104 did not wear a gown at any point during the observation. Interview on 09/13/18 at 1:45 P.M. with LPN #104 directly following the above observation confirmed Resident #272 was in contact isolation precautions due to MRSA in his sacral wound. Further interview confirmed the observation and that he did not wear a gown. Review of the facility policy titled Guidelines for Contact Precautions revised 05/22/18 revealed contact precautions are indicated to prevent and control health-care associated infections transmission or infection with any of the following: MRSA if present in a site that has copious secretions not contained. Further review revealed to wear a clean non-sterile, fluid resistant gown when entering the room if it is anticipated clothing will have substantial contact with the resident or environmental surface or when there is likelihood that organisms from blood, urine, stool, or wound drainage may be on the surfaces or items in the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, policy and procedures review revealed the facility failed to be free of insects in the kitchen's preparation area and service area and of the dishwashing area. This had the potential to affect all the residents in the facility. The faciliy census was 69. Residents Affected - Many Findings include: On 09/10/18 from 8:36 A.M. to 9:09 A.M. during tour of the kitchen revealed a case of bananas with a broom handle inside the box sitting on a milk crate. Dietary Employee #512 removed the broom handle and several nit like insects were exposed on the inside and outside of the box, and in the air. During the tour an observation of the dishwasher area revealed several flies in the area. Further observation revealed a two compartment sink with a large dirty baking sheet in it. The baking sheet had an orange grease like substance on it with nit like insects on and around it. At the time of the observation, Dietary Employee #106 verified the findings. On 09/12/18 at 7:48 A.M. observation of Dietary Employee #512 taking temperatures of the breakfast menu items revealed flies in the kitchen's preparation and service areas. Dietary Employee #512 was noted to physically wave the insects away from the items being served. On 09/12/18 from 9:36 Am to 10:00 AM observation of [NAME] #318 pureeing food for the lunch service revealed two flies around the area. [NAME] #318 stated not being sure why there were flies in the facility. The cook continued to puree the food items. Review of the Pest Control Policies and procedures dated 08/2018 revealed the facility is to maintain an ongoing pest control program to ensure the building is kept free of insects and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 13 of 13