Inspection·October 3, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interviews, the facility failed to ensure a resident was transported to and from off campus medical appointments in a timely manner resulting in delayed treatment. This affected one (Resident #24) of three residents reviewed for transportation to outside appointments. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #24 revealed a readmission date of 06/26/23. Diagnoses included unspecified displaced fracture of second cervical vertebra with routine healing, hypertensive heart and chronic kidney disease, unspecified dementia and left frontal parietal scalp lesion consistent with known angiosarcoma. Resident #24 started radiation treatments to the left frontal parietal scalp on 09/19/23. Review of physician's orders revealed an order for Resident #24 to see the Brain and Spine Physician on 09/18/23. The resident was to be picked up at 8:15 A.M. and his daughter would meet him at the appointment. Special instructions included to have paperwork ready and to have the resident in a regular sized wheelchair. Further review of the medical record and progress notes from 07/03/23 to 09/26/23 revealed Resident #24 was scheduled for an initial appointment to have a stimulation evaluation on 08/09/23. There was no documentation as to why the resident missed the appointment. The stimulation evaluation was rescheduled for 08/16/23 and canceled due to transportation issues. The stimulation evaluation was rescheduled for 08/23/23, the resident missed the appointment and there was no documentation as to why the appointment was missed. The appointment was rescheduled for 08/28/23 and canceled due to transportation issues. Interview on 09/26/23, at 10:46 A.M. with Resident #24's daughter revealed she met her father for his appointment on 09/18/23 and stood in the parking lot while the driver of the van worked for an hour to get her dad out of the van. Resident #24 was an hour late for his appointment. She was upset, because this had happened before, and the facility had been instructed to put her father in a standard sized wheelchair prior to appointments. This was not the first time he was stuck. Resident #24's daughter stated the resident must be in a regular size wheelchair, because the insurance company's transportation contracts do not have transportation vans for wide wheelchairs. Interview on 09/26/23 at 10:55 A.M. with Facility's Transportation Associate (FTA) #112 revealed she arranged transportation for Resident #24 and instructed staff to ensure the resident was in a regular sized wheelchair. Resident #24 was picked up as scheduled on 09/18/23 at 8:15 A.M. About an hour later, FTA #112 received a call from the driver explaining he could not get Resident #24 out of the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366245 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 10/03/2023 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)