F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
Based on review of employee files, staff interview, and review of facility policy the facility failed to provide
training to a new employee upon hire. This affected one employee file State Tested Nursing Assistant
(STNA) #50 of five employee files reviewed. The facility identified eight employees were hired in the last 60
days. This had the potential to affect all 53 residents.
Findings include:
Review of employee file for STNA #50 revealed the employee was hired on 08/13/18. Further review
revealed the employee had previously worked at the facility and had terminated her employment on
03/08/18. The file did not include any training on resident rights, transfer/discharge, Advocate information or
fire and disaster training from the time of re-hire.
Interview with Human Resource Manager #55 on 11/15/18 at 2:30 P.M. revealed no training was provided
to STNA #55 upon re-hire to the facility.
Review of facility policy Orientation Policy dated 10/2016 revealed all newly hired staff members from every
department would be given an orientation to the facility, including introductions, job responsibilities, work
rules, policies and procedures. Orientation was to include safety and emergency policy and procedure
including fire and disaster, accident prevention, infection control and resident rights.
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:
365570
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
365570
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/15/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Park View Care Center
328 West Vine Street
Edgerton, OH 43517
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 0790
Provide routine and 24-hour emergency dental care for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident and staff interview and policy review the facility failed to ensure residents who
requested be seen by a dentist received the ancillary service of the dentist. This affected one resident,
(#39), out of two residents reviewed for ancillary services. The current census was 53.
Residents Affected - Few
Findings include:
Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included schizophrenia, bipolar disorder, weakness, Alzheimer's disease, and dementia.
Review of the Minimum Data Set, (MDS), comprehensive assessment dated [DATE] revealed Resident #39
had impaired cognition.
Review of Resident #39's Health Service Consent Form revealed the resident's guardian consented for the
resident to be seen by the dentistry services on 01/23/18.
Review of Resident #39's care plans dated 02/14/18 revealed a focus for care deficit pertaining to teeth as
evidence by broken/chipped or missing teeth related to impaired cognition. Interventions included to
complete an oral assessment quarterly.
Interview on 11/13/18 at 2:45 P.M. with Resident #39 revealed the resident wanted to be seen by a dentist
to decide if he could get partial dentures. Per Resident #39 he had not been treated or seen by a dentist
since his admission in 01/2018.
Interview on 11/15/18 at 10:30 A.M. with Social Services Designee, (SSD) #1 revealed the facility's
contracted dentist came to the facility and treated residents every three months. Per SSD #1 the dentist
rotated which residents were to be seen by the dentist so each resident on the list may be seen at least
once per year. SSD #1 verified Resident #39 was not on any list to be seen by the dentist since the
resident's admission. Per SSD #1 the resident's guardian signed the consent to be seen upon admission for
dental services. SSD #1 verified Resident #39 had no been seen by the dentist since his admission in
01/2018. SSD #1 stated the resident would be added to the list of residents to be seen by the dentist for the
next visit. SSD #1 stated the dentist was scheduled to visit the facility in 01/2019.
Review of the facility policy titled, Ancillary Services, dated 03/2015 revealed the Social Services Designee
will review the ancillary service provider's list of residents to be seen and make necessary
changes/additions to the schedule in advance of the visit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365570
If continuation sheet
Page 2 of 2
