Inspection·October 24, 2019

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. Based on medical record review, staff interview and policy review the facility failed to ensure a care plan was developed for a resident with high blood pressure and receiving blood pressure medications. This affected one (Resident #12) of five residents reviewed for unnecessary medications. The census was 71. Medical record review for Resident #12 revealed an admission date of 04/30/19. Diagnoses included Non-Alzheimer's dementia. Review of physician orders dated 05/01/19 revealed the resident was receiving Amlodipine 2.5 milligram (mg) once daily and Metoprolol Tartrate 25 mg, twice daily for blood pressure management. Review of the medical record revealed no care plan related to the patient's high blood pressure or use of blood pressure medication. Interview with the Director of Nursing (DON) on 10/24/19 at 1:48 P.M. verified there was not a care plan for management of the resident's blood pressure. Review of the facility policy titled Comprehensive Care Plan Guideline, dated 05/22/18, revealed the purpose of a care plan was to ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. A comprehensive care plan will be developed within seven days of completeness of the admission comprehensive assessment (MDS) 3.0. Furthermore, 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 2 of 7 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 10/24/2019 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, staff and resident interviews and policy review, the facility failed to ensure a physician order was obtained for oxygen administration and failed to ensure oxygen tubing was dated. This affected two (Residents #19 and #49) of 11 residents identified as receiving respiratory treatment. The facility census was 71. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 08/21/18. Diagnoses included chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/14/19, revealed no treatments marked under Section O, Special Treatments. Review of the care plan dated 08/21/19, revealed the resident had a potential for complication related to chronic obstructive pulmonary disease. Interventions included administer oxygen per orders, assess for change in consciousness level, monitor lung sounds per orders or as needed and administer respiratory therapy per orders. Review of the current physician orders revealed no orders related to the administration of oxygen. During observation on 10/21/19 at 3:00 P.M. Resident #19 was in bed with oxygen being administered at two liters per minute via nasal cannula. The tubing had no date as to when it had been applied. Observation on 10/22/19 at 10:45 A.M. revealed Resident #19 in her electric wheelchair with oxygen being administered and no date on the tubing. During in interview on 10/22/19 at 10:45 A.M. Resident #19 stated she always wore her oxygen. During interview on 10/22/19 at 10:46 A.M. State Tested Nursing Assistant (STNA) #71 confirmed the resident was wearing oxygen and the tubing did not have a date. During interview on 10/22/19 at 10:54 A.M., Licensed Practical Nurse (LPN) #100 stated Resident #19 always wore her oxygen except while in the shower. LPN #100 reviewed the physician orders and confirmed there was no order for the use of oxygen. 2. Review of the medical record for Resident #49 revealed an admission date of 09/11/18. Review of the current physician's orders identified an order for oxygen, continuous positive airway pressure (CPAP) at bedtime and to change the oxygen tubing monthly. Observation on 10/21/19 at 10:50 A.M. revealed an oxygenator with tubing was observed next to the head of the bed. A portable oxygen tank with tubing was observed by the resident's window. Also, a CPAP machine with tubing and mask was observed in a pink wash basin on the floor next to the resident bed. The oxygen tubing on the oxygenator, the portable tank and the CPAP machine, along with the CPAP mask and tubing was not dated. There was not protective covering on any of the equipment. Interview with STNA #60, on 10/21/19 at 10:53 A.M. confirmed the equipment was not dated and not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 3 of 7 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 10/24/2019 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 0695 covered. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Guidelines for the Administration of Oxygen, dated 09/17/18, revealed to verify the physcian's order for the procedure [of administering oxygen] and and date the tubing for the date it was initiated. Tubing should be changed monthly and as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 4 of 7 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 10/24/2019 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on record review, interview and policy review, the facility failed to ensure a resident's pain was properly managed when the resident ran out of narcotic pain medication and no alternative pain relief was offered. This resulted in actual harm to Resident #171 who had uncontrolled pain. This affected one (Resident #171) of one resident reviewed for pain management. The facility identified 24 residents on a pain management program. The census was 71. Residents Affected - Few Findings include: Record review for Resident #171 revealed an admission date of 10/06/19. Medical diagnoses included a Baker's cyst behind the left knee and pain from the cyst. Review of physician orders dated 10/09/19 revealed Tylenol 325 milligrams (mg), four times a day as needed for pain. On 10/11/19, Tramadol 50 mg three times a day was ordered for pain. Review of the admission Minimum Data Set (MDS) assessment, dated 10/15/19, revealed Resident #171 was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, and toilet use. Under Section J, Pain Management, the assessment interview was dashed out and the staff assessment for pain was not completed. Review of care plan revealed the resident was at risk for pain due to pain in the left knee related to a Baker's cyst. Interventions were to notify the physician of increased pain, and observe for and record verbal and nonverbal signs and symptoms of pain. Review of the Medication Administration Record (MAR) for October 2019 revealed Tramadol was not given on 10/19/19 at 8:48 P.M. because the medication wasn't available and the facility was waiting on a written prescription. The Tramadol was not given on 10/20/19 at 4:50 A.M. because the drug was still unavailable. According the MAR the last time Resident #171 received the Tramadol was on 10/19/19 between 11:00 A.M. and 2:00 P.M. No other pain medication was documented as given the evening of 10/19/19 or the early morning of 10/20/19. Tylenol was given on 10/20/19 at 10:17 A.M. and was documented as somewhat effective. Interview on 10/21/19 at 10:59 A.M. with Resident #171 revealed she was in excruciating pain on the night of 10/19/19 into the morning of 10/20/19. She rated her pain a 10 out of 10 on the pain scale and stated it made her feel so bad, terrible and the pain brought her to crying. She stated the night was rough. She stated the prescription was sent in on 10/20/19 at 6:30 A.M. and she didn't receive her Tramadol until about 12:30 P.M. She stated she received Tylenol on 10/20/19 at around 10:15 A.M. but it didn't help with the pain. Interview with Registered Nurse (RN) #55 on 10/24/19 at 7:31 A.M. revealed she took care of Resident #171 on 10/19/19 from 7:00 P.M. to 10/20/19 at 7:30 A.M. She stated she could not give the scheduled Tramadol doses on 10/19/19 at 8:45 P.M. and the dose for the morning of 10/20/19 because there was not a written prescription for the medication. She stated she had to have a new prescription for the drug to be able to get it out of the emergency medication box (E-box). RN #55 stated there was Tramadol in the E-box on this night, but since she didn't have a prescription, she could not access the E-box. She stated she called the physician on 10/19/19 at around 9:00 P.M. and he said he would call in the medication. She said she called the pharmacy but didn't know the time and they said they didn't receive anything from the physician so she said she called the physician again on 10/20/19 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 5 of 7 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 10/24/2019 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 0697 Level of Harm - Actual harm 6:00 A.M. The physician said he would send it again. She stated the resident was crying in pain after midnight, but she didn't give her any Tylenol for her pain and couldn't remember what the resident's pain rating was either. She stated the Tramadol ran out on the day shift on 10/19/19 and she didn't know why it wasn't taken care of at that time. Residents Affected - Few Interview with Pharmacy Technician (PT) #103 on 10/24/19 at 9:15 A.M. revealed it was the policy of the pharmacy that there has to be a written prescription for narcotics to be able to pull out of the emergency box in the facility. She stated if there a prescription on file for the resident then the staff could call the pharmacy for a code and pull from the E-box. She said if there wasn't a prescription on file then the facility staff person would have to get the physician to fax a prescription for the medication if it was a controlled substance, such as Tramadol, to the pharmacy. She stated there wasn't any documentation of prescription faxed to the pharmacy from the physician for Resident #17110/20/19 at 6:30 A.M. on 10/20/19. She further said there wasn't any communication from the facility until that time either. Interview with Pharmacist #102 for the facility on 10/24/19 at 9:27 A.M. revealed the first pull from the E-box for the Tramadol was on 10/20/19 at 12:00 P.M. and another one was at 6:00 P.M. Interview with Licensed Practical Nurse (LPN) #27 on 10/24/19 at 10:19 A.M. revealed she worked on 10/19/19 and 10/20/19 from 7:00 A.M. to 7:30 P.M. She didn't know the Tramadol had run out for Resident #171. She stated she called the pharmacy on 10/20/19 before her medication pass and they said they didn't get the prescription yet. She called the physician on 10/20/19 shortly thereafter, but the physician said he had faxed the prescription to the pharmacy and sent her the confirmation of it. She stated Resident #171 was in pain and was very uncomfortable. Review of progress notes from 10/19/19 through 10/20/19 contained no documentation the facility had called the physician for the prescription. Review of the facility policy titled Controlled Substance Prescriptions, dated 01/01/17, revealed before a controlled substance can be dispensed, the pharmacy must have a clear, complete, and signed written prescription from a person lawfully authorized to prescribe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 6 of 7 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 10/24/2019 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 Based on observation, staff interview and policy review, the facility failed to deliver clean laundry for three (Residents #222, #226 and #66) in a sanitary manner. There were 71 facility residents. Residents Affected - Few Findings include: Observation on 10/23/19 at 7:54 A.M. of the laundry delivery cart on hallway 300, revealed the cart had a zipped cover enclosing the entire cart. Several piles of folded laundry and a blanket were uncovered on the top of the cart. Interview on 10/23/19 at 7:55 A.M. with Laundry staff #16 confirmed the uncovered laundry on the top of the cart was for Residents (#222 and #226) and were place on the top because there was no room for them inside the covered cart. Observation of the clean laundry area on 10/24/19 at 9:20 A.M. revealed clean laundry was uncovered on top of enclosed cart for resident #66 who was a new admission on the rehab unit including two nightgowns. At that time, interview with Laundry staff #9 verified the clean laundry would be delivered uncovered on top of the cart down the halls to Resident #66 on the rehab unit. Review of the policy titled Laundry Operations, revised 02/05/18, revealed linen rooms were restocked during the day using the clean linen cart which was covered at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 7 of 7