Health inspection·March 7, 2019

F 0558 so that the nurse can schedule alternate transportation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 2 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on medical record review and staff interview, the facility failed to ensure the physician's order for a resident's code status matched the State of Ohio Do Not Resuscitate (DNR) document. This affected one (#23) of one residents reviewed for advance directives. The facility census was 43. Findings include: Review of Resident #23's medical record revealed an admission date of 04/16/18. Diagnoses included atrial fibrillation, hypertension, and cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment identified the resident as being cognitively intact. Review of Resident #23's physician's orders revealed an order identifying the resident as being a full code. This order was initiated on 05/16/18. Review of the State of Ohio Do Not Resuscitate document identified the resident as requesting a Do Not Resuscitate Comfort Care (DNRCC) status. This was signed by the physician on 03/01/19. Interview with Corporate Nurse #500 on 03/06/19 at 12:17 P.M. confirmed the resident had a signed and advanced directive identifying the resident as being a DNRCC. However, she confirmed Resident #23's physician's order indicates the resident as being a full code. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 3 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected two (#13 and #32) of three residents reviewed for hospitalizations. The facility census was 43. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 09/17/18. Diagnoses included pneumonia, cognitive communication deficit, hypertension, and major depressive disorder. Review of Resident #13's medical record revealed the resident was sent out to the hospital on [DATE] and returned on 12/10/18. There was no evidence in Resident #13's medical record that the resident and/or resident representative was notified in writing the reasoning for the transfer to the hospital. Interview with Corporate Registered Nurse #500 on 03/07/19 at 12:59 P.M. confirmed there was no evidence written notification was provided to the resident and/or resident representative for the reasoning for the transfer to the hospital. 2. Review of medical record for Resident #32 revealed he was admitted on [DATE]. Medical diagnoses included Alzheimer's Disease. Review of progress notes dated 10/17/18 for Resident #32 revealed he was taken to the hospital for a suspected fracture. The resident returned on 10/25/18. The note was silent to information regarding transfer discharge paperwork for the resident. Review of progress notes dated 11/25/18 at 8:00 P.M. revealed Resident #32 was sent to the hospital. He returned on 11/30/18. The note was absent for transfer discharge paperwork being sent with the resident to the hospital. Interview with Business Office Manage #501 on 03/07/19 at 11:42 A.M. verified she couldn't find information regarding transfer discharge paperwork for Resident #32. Interview with Corporate Registered Nurse (CRN) #500 on 03/07/19 at 11:46 A.M. stated the transfer discharge paperwork was located at the nursing station and would be sent with the resident to the hospital and should be charted in the nursing progress notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 4 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to issue written notice of the bed hold policy to a resident/resident's representative. This affected two (#13 and #32) of three residents reviewed for hospitalizations. The facility census was 43. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 09/17/18. Diagnoses included pneumonia, cognitive communication deficit, hypertension, and major depressive disorder. Review of Resident #13's medical record revealed the resident was sent out to the hospital on [DATE] and returned on 12/10/18. There was no evidence in Resident #13's medical record that the resident and/or resident representative was notified in writing of the bed hold policy or bed hold days. Interview with Corporate Registered Nurse #500 on 03/07/19 at 12:59 P.M. confirmed there was no evidence written notification was provided to the resident and/or resident representative regarding their bed hold policy. Review of the facility policy titled Bed Hold Policy, dated 11/23/16, revealed the campus will inform the residents in advance of their option to make bed-hold payments as well as the amount of the facility's charge to hold a bed. 2. Review of medical record for Resident #32 revealed he was admitted on [DATE]. Medical diagnoses included Alzheimer's Disease and congested heart failure. Review of progress notes dated 10/17/18 for Resident #32 revealed he was taken to the hospital and returned on 10/25/18. The note revealed a bed hold notification was given to the paramedics at the time of leaving the facility. Review of progress notes dated 11/25/18 at 8:00 P.M. revealed Resident #32 was sent to the hospital when he became difficult to arouse. He returned on 11/30/18. The note was absent for a bed hold notice. Review of progress notes dated 12/13/18 at 7:53 A.M. Resident #32 was send out to the hospital and returned on 12/18/18. The note revealed the bed hold notice was sent with the resident to the hospital. Interview with Business Office Manage #501 on 03/07/19 at 11:42 A.M. revealed she wasn't able to find a bed hold notification for Resident #32. Interview with Corporate Registered Nurse (CRN) #500 on 03/07/19 at 11:46 A.M. stated the bed hold policy paperwork was located at the nursing station should be charted in the nursing progress notes that it was given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 5 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assess the cognitive status on the comprehensive Minimum Data Set (MDS) assessment (Section C) for five (#28, #31, #32, #36, and #198) out of 17 residents reviewed for MDS assessments. The census was 43. Findings include: 1. Medical record review for Resident #31 revealed an admission dated on 03/05/18. Medical diagnoses included renal insufficiency and diabetes. Review of the annual MDS assessment, dated 02/08/19, revealed she was not assessed for cognitively status. 2. Review of medical record for Resident #32 revealed he was admitted on [DATE]. Medical diagnoses included Alzheimer's Disease. Review of the significant change MDS assessment, dated 02/08/19, revealed the resident wasn't assessed for cognitive status. 3. Review of Resident #28's medical record revealed an admission date of 01/23/19. Diagnoses included cognitive communication deficit, chronic kidney disease stage three, and hypertension. Review of the admission MDS assessment, dated 01/30/19, revealed a Brief Interview for Mental Status (BIMS) interview should be conducted, however, Resident #28's BIMS was not assessed. 4. Review of the medical record for Resident #36 revealed an admission date of 02/05/19. Diagnoses included chronic diastolic heart failure, difficulty in walking, muscle weakness, other symbolic dysfunctions, hypertension, myocardial infarction, and adult failure to thrive. Review of the comprehensive MDS assessment, dated 02/19/19, revealed Section C was not completed. 5. Review of the medical record for Resident #198 revealed an admission date of 02/17/19. Diagnoses included cognitive deficit, type two diabetes mellitus, chronic obstructive pulmonary disease, and hypertension. Review of Resident #198's comprehensive MDS assessment, dated 02/24/19, revealed Section C was not completed. Interview with Social Worker #51 on 03/05/19 at 3:50 P.M. revealed she wasn't able to complete the interview for Section C for Resident #28, #31, #32, #36, and #198. She stated if she wasn't able to complete the assessment in the assessment reference date timeframe the assessment should have a dash in the interview, which means there were dashes in all the areas of the Section C except for the first question which was should a BIMS be conducted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 6 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete the cognitive section of the quarterly Minimum Data Set (MDS) assessments (Section C) for two (#8 and #13) out of 17 residents reviewed for MDS assessments. The census was 43. Residents Affected - Few Findings include: 1. Review of medical record revealed Resident #8 was admitted on [DATE]. Medical diagnoses included dementia without behavioral disturbance. Review of quarterly MDS assessment, dated 12/13/18, revealed Resident #8 was not assessed for cognitive patterns. 2. Review of Resident #13's medical record revealed an admission date of 09/17/18. Diagnoses included cognitive communication deficit, hypertension, and major depressive disorder. Review of Resident #13's quarterly MDS assessment, dated 12/17/18, revealed a BIMS interview should be conducted, however, Resident #13's Brief Interview for Mental Status (BIMS) was not assessed at any point during the seven day assessment reference date time period. Interview with Social Worker #51 on 03/05/19 at 3:50 P.M. revealed she wasn't able to complete the interview for Section C for Resident #8 and #13. She stated if she wasn't able to complete the assessment in the assessment reference date timeframe the assessment should have a dash in the interview, which means there were dashes in all the areas of the Section C except for the first question which was should a BIMS be conducted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 7 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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. Based on medical record review, staff and resident interviews, and policy review, the facility failed to ensure care conferences were conducted on a routine basis for one (#31) of one residents reviewed for care conferences during the annual survey. The census was 43. Findings include: Medical record review for Resident #31 revealed an admission dated on 03/05/18. Medical diagnoses included renal insufficiency and diabetes mellitus. Review of care conferences for Resident #31 revealed there was no evidence of a care conference after 06/25/18. Interview with Resident #31 on 03/04/19 at 3:51 P.M. revealed she the facility only held two care conferences for her since admission. Interview with Director of Social Services #1 on 03/05/19 at 2:00 P.M. verified there was no care conference conducted after 06/25/18 for Resident #31. Review of policy titled Resident's First Meeting Guidelines, dated 05/22/18, revealed the purpose was to facilitate communication and participation regarding the resident's plan of care, medical condition, and care needs between the resident, family, responsible party, and care giver. The policy further revealed a care conference should be conducted at a minimum quarterly and with every significant change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 8 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, staff interview, and policy review, the facility failed to routinely ensure controlled medication were present and accounted for in one (400 Hall) out of two medication room refrigerators. The census was 43. Findings include: Observation of the locked narcotic box in the medication room on the 400 Hall on 03/07/19 at 2:10 P.M. revealed there was a package with two vials of the anti-anxiety medication lorazapam 2 milligram/milliliters in the refrigerator. Review of Contingency Controlled Substance Inventory Log dated from 02/25/19 through 03/06/19 revealed the logs did not have the name of the drug or dosage and was not signed off as being present and accurate by anyone on 2/27 for the night shift, 2/28 for the day, evening and the night shift, 03/03 for the day, evening, and night shifts, 03/04 for the day, evening and night shifts, 03/05 for evening and night shifts, and 03/06 for the day, evening and night shift. Interview with Licensed Practical Nurse (LPN) #47 on 03/07/19 at 2:12 P.M. verified the nurses who worked those above mentioned shifts did not sign off the lorazapam vials were present and counted. Review of facility policy titled Guidelines for Narcotic Counts, dated 09/23/18, revealed each controlled drug shall have a corresponding count sheet to track distribution and the narcotic book shall contain a sheet providing space for the off going and oncoming nursing staff to record their signature indicating the narcotics had been reviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 9 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **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 on anti-psychotic medications was assessed for side effects and the failed to ensure non-pharmacological interventions were initiated before an as needed pain medication was given. This affected one (#32) of five residents reviewed for unnecessary medications. The census was 43. Residents Affected - Few Findings include: Review of medical record for Resident #32 revealed he was admitted on [DATE]. Medical diagnoses included Alzheimer's Disease. Review of the 14 day Minimum Data Set (MD) assessment, dated 11/08/18, revealed he was cognitively impaired. Review of physician orders dated 05/21/18 revealed the resident was to receive the anti-psychotic medication Seroquel 50 milligrams (mg) at bedtime. Review of the Abnormal Involuntary Movement Scale (AIMS) assessment, for side effects of anti-psychotic medication, revealed the last assessment was completed on 06/01/18. Review of care plan dated 06/01/18 for anti-psychotic drug use for Resident #32 revealed an intervention to perform AIMS testing per guidelines of the facility. Interview with Director of Health Services (DHS) on 03/06/19 at 4:41 P.M. verified Resident #32 should have an AIMS assessment had not been completed since 06/01/18 and should be conducted every six months. Review of policy titled Abnormal Involuntary Movement Scale, dated 05/22/18, revealed the AIMS assessment will be repeated for residents taking an anti-psychotic medication every six months or as needed for displaying symptoms of tardive dyskinesia. Additionally, review of physician orders dated 12/29/18 for Resident #32 revealed the pain medication Norco tablet 5-325 mg was ordered every six hours as needed for pain. Review of care plan for pain dated 06/01/18 revealed to attempt non-pharmacological interventions for as needed pain medication. Review of Medication Administration Record (MAR) from 01/01/19 through 01/31/19 revealed pain medication was administered 16 with no evidence of any non-pharmacological interventions being attempted. Interview with DHS on 03/06/19 at 5:20 P.M. verified there were no attempts for non-pharmacological interventions before as needed pain medication was administered to Resident #32. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 10 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, staff interview and policy review, the facility failed to ensure medications were administered with a rate of less than 5%. This affected two (#32 and #90) of five residents observed during the medication pass. There were two errors with 31 opportunities for errors for an error rate of 6.45%. The facility census was 43. Residents Affected - Few Findings include: 1. Observation of the medication administration on 03/05/19 from 9:09 A.M. until 9:14 A.M. with Licensed Practical Nurse (LPN) #47 revealed she prepared Resident #32's medications. These medications included dicyclomine 10 milligram (mg) one tablet, Lasix 40 mg one tablet, lisinopril 20 mg one tablet, memantine 10 mg one tablet, Paxil 20 mg one tablet, Sotalol 80 mg half tablet to equal 40 mg, spironolactone 25 mg one tablet, Vascepa (Omega-3) one gram one tablet, and Restasis 05% eye drops. On 03/05/19 at 9:13 A.M. LPN #47 voiced Resident #32 was ordered to have Tylenol 500 mg one tablet, however, it was unavailable. At this time LPN #47 confirmed she would be administering eight pills, and administered Resident #32 his medications. Review of Resident #32's medical record revealed a physician order for Tylenol 500 mg one tablet two times a day. Interview with LPN #47 on 03/05/19 at 10:00 A.M. confirmed she was not able to administer Resident #32's Tylenol 500 mg due to it not being available. 2. Observation of the medication administration on 03/05/19 from 9:18 A.M. until 9:32 A.M. with LPN #47 revealed she prepared Resident #90's medications. These medications included amlodipine 10 mg one tablet, aspirin 81 mg one tablet, Citracal with D3 250/500 mg one gummie, Vitamin B-12 1000 mcg one tablet, Colace 100 mg one tablet, ferrous sulfate 325 mg one tablet, folic acid 1 mg one tablet, K-Phos-Neutral 250 mg one tablet, magnesium oxide 400 mg 0.5 tablet to equal 200 mg, metoprolol 50 mg one tablet, omeprazole 40 mg one tablet, prednisone 10 mg one tablet, Senna 8.6 mg two tablets, Lyrica 50 mg one tablet, tramadol 50 mg one tablet and Systane 0.4-0.3% eye drops. At 9:32 A.M. LPN #47 confirmed she was administering the resident 15 pills and one gummy. LPN #47 then was observed to administer Resident #90 her medications. Review of the medical record revealed Resident #90, had a physician order for folic acid 1 mg, administer two tablets once daily. Interview with LPN #47 on 03/05/19 at 10:00 A.M. confirmed she only administered folic acid 1 mg one pill, however, she should have administered two pills. Review of the facility policy titled Medication Administration-General Guidelines, dated 11/18, indicated medications are administered as prescribed. The procedure indicated the right resident, right drug, right dose, right route and right time are applied for each medication being administered and a triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration 1.) when the medication is selected 2.) when the dose is removed from the contained 3.) just after the dose is prepared and the medication put away. It indicated that prior to administration of any medication, the medication and dosage schedule on the residents medication administration record are compared with the medication label. It revealed medications are administered in accordance with written orders of the prescriber. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 11 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0759 There were two errors with 31 opportunities for errors for an error rate of 6.45%. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 12 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 - Many 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. Based on observation, staff interview, review of manufacturer's recommendations, and policy review, the facility failed to ensure medications were dated upon opening and removed from use when expired. This affected two (100 Hall and 200 Hall) of two medication carts reviewed and two (100/200 Hall and 400 Hall) of two medication rooms. The facility census was 43. Findings include: 1. Observation of the 200 Hall medication cart with Licensed Practical Nurse (LPN) #10 on 03/07/19 from 1:35 P.M. until 1:45 P.M. revealed there was an opened and undated bottle of Brimonidine 0.15% eye drops, a bottle of Lumigan 0.01% eye drops that were opened and undated, and an opened and undated Spiriva Respimat 1.25 mcg/actuation inhaler. Additionally, there was a bottle of olopatadine antihistamine 0.2% eye drops that was opened and undated. Furthermore, there was an opened bottle of Humalog 100 units/milliliter vial that contained an opened date of 01/31/19. Review of the manufacturer's recommendations for Humalog revealed to discard opened vials within 28 days. Interview with LPN #10 on 03/07/19 at 1:46 P.M. confirmed the above medications which were opened and undated and confirmed the Humalog was expired. 2. Observation of the 100/200 Hall medication storage room with LPN #10 on 03/07/19 at 1:47 P.M. revealed there were three bottles of Tuberculin Purified Protein Deriative, that were opened and undated. Review of the manufacturer's recommendations for Tuberculin Purified Protein Derivative revealed to discard opened vials within 30 days. Interview with LPN #10 on 03/07/19 at 1:49 P.M. confirmed the Tuberculin Purified Protein Derivative was opened and undated. 3. Observation of the 100 Hall medication cart with LPN #10 on 03/07/19 from 1:55 P.M. until 2:01 P.M. revealed an opened and undated bottle of Brigandine 0.2% eye drops, an opened and undated bottle of dorzolamide-timolol 22.3-6.8 milligram/ml eye drops, an opened and undated bottle of Latanoprost 0.005% eye drops. Additionally, there was a tube of erythoromycin ointment 0.5% that was opened and undated, a bottle of Lumigan 0.01% eye drops that were opened and undated and a bottle of timolol maleate 0.5% eye drops that were opened and undated. Interview with LPN #10 on 03/07/19 at 2:02 P.M. confirmed the above medications were opened and undated. 4. Observation of the 400 Hall medication room with LPN #47 on 03/07/19 at 2:10 P.M. revealed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 13 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 vial of Pneumovax 0.5 milliliters (ml) that had an expiration date of 02/16/19. Level of Harm - Minimal harm or potential for actual harm Interview with LPN #47 at the time of the observation confirmed the Pneumovax was expired. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Medication Storage in the Facility, dated 11/18, revealed certain medications or package types such a ophthalmic's and multiple dose injectable vials require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. It indicated when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. A date opened sticker shall be placed on the medication. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. The medication administration personnel will check the expiration date of each medication before administering it. It revealed that all expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Event ID: Facility ID: 366461 If continuation sheet Page 14 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on medical record review, staff interview, and policy review the facility failed to ensure the physician was notified timely of abnormal laboratory (lab) results for one (#13) of three residents reviewed for hospitalization. The facility census was 43. Findings include: Review of Resident #13's medical record revealed an admission date 09/17/18. Diagnoses of pneumonia, hypertension, major depressive disorder, and pain in right hip. Review of Resident #13's medical record revealed an undated lab requisition form that revealed an order for a basic metabolic panel (BMP), complete blood count with differential (CBC with diff), and hemoglobin and hematocrit (H&H) be obtained immediately (STAT). The requisition indicated these labs were drawn on 12/04/18 at 1:50 P.M. Review of the lab results revealed labs were reported on 12/04/18 at 4:07 P.M. with the resident noted to have a high white blood cell count (a blood test to detect infections) of 17.3. The normal range was identified as being 3.8-10.8. Review of Resident #13's nurses notes revealed a note on 12/05/18 at 1:52 P.M. that revealed this nurse spoke with the nurse practitioner regarding the resident's STAT labs. A new order was obtained to send the resident out to the hospital for evaluation. There was no evidence that the physician or nurse practitioner was notified of the results of the STAT labs prior to 12/05/18 at 1:52 P.M. Additional review of the lab results revealed the physician was notified on 12/05/18 and provided orders to send the resident to the emergency room for evaluation. Interview with the Director of Nursing (DON) on 03/06/19 at 11:00 A.M. confirmed there was no evidence the physician or nurse practitioner was notified of the STAT lab results until 12/05/18 at 1:52 P.M. when an order was obtained to send the resident to the hospital for evaluation. Review of the facility undated lab policy titled American Health Associate revealed all STAT and critical results are phoned timely to appropriate personnel. Review of the facility policy titled Provider Notification Guidelines, dated 05/23/18, revealed the provider should be notified of critical lab results or an immediate need by phone as soon as the results are known with a response received before the call is completed when possible. It revealed that a diagnostic test results require a response from the physician noting they have reviewed the test results, and test results out of normal range should note whether or not treatment is desired. If the facility has not had a response to abnormal test results or request for physician/provider intervention within 12 hours the nurse on duty will call the physician to obtain further instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 15 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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** Based on observations, record review, staff interview, and review of the facility policy, the facility failed to ensure gloves were worn during the administration of eye drops. This affected two (#32 and #90) residents observed during medication administration. Additionally, the facility failed to ensure the glucometer was sanitized between two residents. This affected two (#7 and #34) of seven residents who required blood sugar checks. The facility also failed to ensure hand hygiene was performed, sanitization was completed with the use of a dinamap, and that a resident was in contact precautions per physician orders. This affected one (#28) of two residents reviewed for infections. The facility census was 43. Residents Affected - Some Findings include: 1. Observations of medication administration on 03/05/19 from 9:09 A.M. until 9:14 A.M. with Licensed Practical Nurse (LPN) #47, revealed she prepared Resident #32's medications including Restasis (eye drop for chronic dry eyes) 0.05%. On 03/05/19 at 9:14 A.M., LPN #47 was observed to administer Resident #32 his Restasis 0.05% eye drops one drop to both eyes without wearing gloves. 2. Observations of the medication administration on 03/05/19 from 9:18 A.M. until 9:32 A.M. with LPN #47, revealed she prepared Resident #90's medications. These medications included Amlodipine (blood pressure medication) 10 milligram (mg) one tablet, Aspirin 81 mg one tablet, Citracal plus D3 (vitamin) 250/500 mg one gummie, Vitamin B 12 1000 micrograms (mcg) one tablet, Colace (stool softener) 100 mg one tablet, Ferrous Sulfate (iron) 325 mg one tablet, Folic Acid 1 mg one tablet, K-Phos-Neutral 250 mg one tablet, Magnesium Oxide 400 mg 0.5 tablet to equal 200 mg, Metoprolol (blood pressure medication) 50 mg one tablet, Omeprazole (medication for gastroesophageal reflux disease GERD) 40 mg one tablet, Prednisone (steroid) 10 mg one tablet, Senna (medication for constipation) 8.6 mg two tablets, Lyrica (medication for nerve pain) 50 mg one tablet, Tramadol (pain medication) 50 mg one tablet and Systane 0.4-0.3% eye drops. During this observation, LPN #47 was observed to pop the Ferrous Sulfate 325 mg out of the medication package and the medication landed on the medication cart. LPN #47 picked the pill up with her bare hands off of the medication cart and placed the pill inside the medication cup. While preparing the medications, LPN #47 was observed to pop the Senna 8.6 mg two tablets, and the Tramadol 50 mg one tablet from the medication package into her bare hands, and then she placed the medications into the medication cup. On 03/05/19 at 9:31 A.M., LPN #47 was observed to administer Resident #90's Systane 0.4-0.3% eye drops, one drop to both eyes. LPN #47 was not observed to wear gloves during administration of the eye drops. Interview with LPN #47 on 03/05/19 at 9:37 A.M., confirmed she did not wear gloves for Resident #32 or Resident #90, while administering their eye drops and verified she should have. LPN #47 confirmed she popped the pills out into her bare hand and then placed the pills into the medication cup for administration. She verified she should not have touched the pills and should have popped them into the medication cup. Additionally, she confirmed she dropped Resident #90's Ferrous Sulfate on top of the medication cart, picked the pill up with her bare hands and placed the medication into the medication cup for administration. LPN #47 confirmed she should have disposed of the medication and replaced them. 3. Observations on 03/05/19 at 12:02 P.M., revealed LPN #10 checked Resident #7's blood sugar. LPN #10 then returned to the medication cart and cleansed the glucometer with an alcohol pad. LPN #10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 16 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 was not observed to properly sanitize the glucometer before or after use. Level of Harm - Minimal harm or potential for actual harm Observations on 03/05/19 at 12:19 P.M., revealed LPN #10 checked Resident #34's blood sugar using the same glucometer she used with Resident #7. After obtaining Resident #34's blood sugar, she returned to the medication cart and cleansed the glucometer with an alcohol pad. LPN #10 was not observed to properly sanitize the glucometer before or after use. Residents Affected - Some Interview with LPN #10 on 03/05/19 at 12:22 P.M., confirmed she cleansed the glucometer with an alcohol pad between Resident #7 and Resident #34. She verified she typically uses bleach wipes, however, she didn't have any on her cart and used the alcohol pads. 4. Review of Resident #28's record revealed an admission date of 01/23/19. Diagnoses included cognitive communication deficit, non-pressure chronic ulcer of the right heel and midfoot with necrosis of the bone, non-pressure chronic ulcer of the right calf with the fat layer exposed, chronic kidney disease stage three, type two diabetes mellitus, and Methicillin-resistant staphylococcus aureus (MRSA). Review of the admission minimum data set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) should be conducted, however, Resident #28's BIMS was not assessed. It identified the resident as requiring an extensive two person assist with bed mobility; extensive two person assist with transfers; limited one person assist with dressing; supervision set up assist with eating; extensive one person assist with toilet use and limited one person assist with personal hygiene. Review of Resident #28's physician orders revealed an order initiated on 01/23/19 for contact precautions for MRSA in the wound three times a day. Review of the March 2019 treatment administration record, revealed staff were signing off on the treatment every shift indicating Resident #28 was in contact precautions for MRSA in the wound. Interview with LPN #10 on 03/04/19 at 10:50 A.M., revealed Resident #28 was no longer in isolation. She verified the residents wound was covered; so unless staff were touching the wound, no personal protective equipment (PPE) needed to be worn. Observation on 03/04/19 at 10:50 A.M., revealed there was an isolation cart located inside of the residents room. However, there was no sign located on the outside of the residents room to identify the resident being in contact precautions. Observation on 03/04/19 at 3:29 P.M., revealed LPN #63 entered Resident #28's room without gloves and without any other PPE. LPN #63 was observed to obtain the residents vital signs using a dinamap blood pressure machine (portable blood pressure monitor). LPN #63 then exited Resident #28's room without washing or sanitizing her hands nor sanitizing the dinamap. She then entered room [ROOM NUMBER] and obtained a blood pressure. Interview with LPN #63 on 03/04/19 at 3:37 P.M., revealed Resident #28 was no longer in contact isolation. She stated the resident was in isolation, however, was taken out the beginning of the week. She confirmed she did not wear gloves nor any other PPE while obtaining Resident #28's blood pressure. LPN #63 confirmed she did not wash or sanitize her hands after obtaining Resident #28's blood pressure. Additionally, LPN #63 confirmed she did not sanitize the dinamap after obtaining Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 17 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 #28's blood pressure and prior to moving onto the next resident. Level of Harm - Minimal harm or potential for actual harm Interview with the DON on 03/04/19 at 3:42 P.M., confirmed Resident #28 had an order to be in contact precautions for MRSA in the wound. He stated staff should be wearing gloves when they were providing care to him. An additional interview with the DON on 03/04/19 at 4:02 P.M., confirmed there was no isolation sign on the door to see the nurse before entering and confirmed there should have been. Residents Affected - Some Interview with Corporate Nurse #500 on 03/04/19 at 4:07 P.M., confirmed the dinamap should have been sanitized after obtaining Resident #28's blood pressure. Review of the facility policy titled, Glucometer Cleaning and Control Test Guidelines, dated 08/02/17, revealed the Center for Disease Control (CDC) indicated the Hepatitis B Virus (HBV) can survive for at least one week in dried blood on environmental surfaces or on contaminated instruments. The following procedures provide the guidance for cleaning and decontamination of glucometers that may be contaminated with blood and body fluids . The procedure indicated if glucometers were used from one resident to another, they should be cleaned and disinfected after each use. Review of the manufacturers's recommendations for Cleaning and Disinfecting the Meter, revealed the meter should be cleaned and disinfected after use on each resident. The recommendation indicated the disinfection procedure was needed to prevent the transmission of blood-borne pathogens. It revealed a variety of the most commonly used registered wipes that have been tested and approved for cleaning and disinfecting of the Assure Prism multi blood glucose monitoring system. The disinfectant wipes listed below have been shown to be safe for use with this meter. The wipes identified were: Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels and Bleach, PDI Super Sani-Cloth Germicidal Disposable Wipe and CaviWipes. Review of the facility policy titled, Medication Administration-General Guidelines, dated 11/18, revealed the person administering medications adheres to good hand hygiene before beginning medication administration, prior to handling any medications, after coming into direct contact with a resident, before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and before and after administration of medications via enteral tubes. The policy also revealed hand hygiene was to be performed before putting on examination gloves and upon removal for administration of ophthalmic medications. Review of the facility policy titled, Guidelines for Contact Precautions, dated 05/22/18, revealed the purpose was to prevent the spread of infectious disease organisms. The policy addressed standard precautions such as wearing gloves, good hand washing before, after and between residents should always be followed. The policy indicated to wear gloves before contact with the resident or environmental objects and change gloves and wash hands after having direct contact with the resident, possible infective material, or potentially contaminated environmental objects and between each resident care intervention. Further review of the policy indicated a stethoscope, thermometer, and scissors for care should be dedicated to the individual resident and left in the room. If use of common equipment was unavoidable, then adequate cleaning and disinfecting was necessary before use with other residents. The policy revealed to post a sign at the resident's door to advise the visitors to report to the nurse's station before entering the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 18 of 19 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of the facility policy and staff interviews, the facility failed to ensure one resident received the pneumococcal vaccination. This affected one (#7) of five residents reviewed for pneumococcal vaccinations. The facility census was 43. Residents Affected - Few Findings include: Review of Resident #7's record revealed an admission date of 05/29/18. Diagnoses included dysphagia, difficulty in walking, acute and chronic respiratory failure with hypoxia, major depressive disorder, diabetes mellitus Type two, unspecified osteoarthritis, and neuromuscular dysfunction of the bladder. Further review of Resident #7's record revealed there was no evidence Resident #7 had received the pneumococcal vaccine since admission. On 03/06/19 at 2:22 P.M., an interview with the Director of Nursing (DON), revealed Resident #7 had been offered the pneumococcal vaccination but had never received it. On 03/06/19 at 2:32 P.M., an interview with Resident #7, revealed she had been offered the vaccination and signed the consent form, but had never received it. On 03/06/19 at 2:00 P.M., review of the undated facility policy titled, Guidelines for Influenza and Pneumococcal Immunizations, revealed upon admission each resident/responsible party will be provided with information regarding the risk and benefits of influenza and pneumococcal immunization. A copy will be placed in the medical record. Upon admission each resident/responsible party will sign an acceptance/refusal of immunization and a copy will be scanned into the medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366461 If continuation sheet Page 19 of 19