Health inspection·May 4, 2023

F 0558 and from the floor to ensure timely responses to the resident's request and needs. 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: 365570 If continuation sheet Page 2 of 12 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 05/04/2023 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, record review, review of personnal fund accounts, and review of the facility policy, the facility failed to ensure authorizations to open a Resident Trust account were signed by the resident. This affected two (Resident #3 and Resident #25) of six residents reviewed for Resident Trust accounts. The facility census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 02/25/20. Review of the Resident Fund Management Service Authorization revealed Resident #3's authorization to open a Resident Trust account was not signed by the resident, but was signed by a previous administrator of the facility on 10/20/20. 2. Review of the medical record for Resident #25 revealed a readmission date of 07/16/22. Review of the Resident Fund Management Service Authorization revealed Resident #25's authorization to open a resident trust account was not signed by the resident, but was signed by a previous administrator of the facility on 10/20/20. Interview on 05/03/23 at 3:55 P.M. with Business Office Manager (BOM) #332 confirmed the Resident Trust agreements were signed by a former administrator at the facility and no resident signature was on the form. Review of the undated Resident Trust Fund Policy and Procedure Manual revealed all residents that wish to have a resident fund must sign a Resident Personal Funds Authorization to be kept on file. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 3 of 12 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 05/04/2023 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, review of personnal fund accounts, and review of the facility policy, the facility failed to ensure residents were notified when their personal funds account balance was within $200.00 of the Medicaid resource limit. This affected three (#1, #3 and #25) of six residents reviewed for personal funds. Further, the facility failed to ensure resident funds were disbursed in a timely manner after discharge from the facility. This affected two (#161 and #162) of six residents reviewed for resident trust accounts. The facility census was 58. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of [DATE] and a readmission date of [DATE] with a payer source of Medicaid. Review of the Resident Statement (bank statement) dated [DATE] through [DATE] revealed Resident #1 consistently carried a balance exceeding $3000.00. The account balance on [DATE] was $4005.35 after monthly care costs were withdrawn for [DATE]. There was no evidence the resident was notified when the personal fund account balance was within $200.00 of the Medicaid resource limit. 2. Review of the medical record for Resident #3 revealed an admission date of [DATE] with a payer of Medicaid. Review of the Resident Statement dated [DATE] through [DATE] revealed Resident #1 consistently carried a balance exceeding $3000.00. The account balance on [DATE] was $5068.80 after monthly care costs were withdrawn for [DATE]. There was no evidence the resident was notified when the personal fund account balance was within $200.00 of the Medicaid resource limit. 3. Review of the medical record for Resident #25 revealed a readmission date of [DATE] with a payer source of Medicaid. Review of the Resident Statement dated [DATE] through [DATE] revealed Resident #25 consistently carried a balance exceeding $3000.00. The account balance on [DATE] was $4586.94 after monthly care costs were withdrawn for [DATE]. There was no evidence the resident was notified when the personal fund account balance was within $200.00 of the Medicaid resource limit. Interview on [DATE] at 2:55 P.M. with the Business Office Manager (BOM) #332 confirmed Resident #1, Resident #3, and Resident #25 all received Medicaid funding and were subject to Medicaid's resource limit of $2000.00. Further interview revealed the BOM #332 did not issue notifications to Resident #1, Resident #3, and Resident #25 regarding the excess money in their accounts. Review of the undated policy titled Resident Trust Fund Policy and Procedure Manual revealed the facility was required to notify residents when personal funds reached $200.00 less than the maximum allowed limit to qualify for Medicaid. The maximum is $2000.00 for the State of Ohio. A letter is to be issued to the resident or responsible party, notifying them that a spend-down of funds is necessary to maintain eligibility. 4. Review of the medical record for Resident #161 revealed an admission date of [DATE] and expired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 4 of 12 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 05/04/2023 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 0569 under the care of hospice on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the payer source for Resident #161 revealed he was covered by Hospice Private Pay. Residents Affected - Some Review of the Resident Fund Management Service (RFMS) Resident Statement revealed Resident #161 had an account balance of $2,746.65 on [DATE]. Further review revealed Resident #161's account accrued $21.12 in interest between [DATE] and [DATE] for a total balance of $2,767.77 on [DATE]. 5. Review of the medical record for Resident #162 revealed an admission date of [DATE]. Resident #162 expired on [DATE] under the care of hospice. Review of the payer source for Resident #162 revealed she was covered by Hospice Medicaid. Review of the RFMS Resident Statement revealed Resident #162 had an account balance of $3,708.02 on [DATE]. Further review revealed Resident #162's account accrued $34.75 in interest between [DATE] and [DATE] for a total balance of $2,767.77 on [DATE]. Interview on [DATE] at 2:55 P.M. with BOM #332 confirmed the Resident Trust accounts for Resident #161 and Resident #162 were not disbursed timely and BOM #332 further confirmed she requested checks for disbursement for both accounts on [DATE]. Review of the undated policy titled Resident Trust Fund Policy and Procedure Manual provided no guidance regarding the timely disbursement of resident funds upon discharge from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 5 of 12 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 05/04/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and review of facility policy, the facility failed to provide timely incontinence care to one resident (Resident #10) dependent for incontinence care. The facility identified 33 residents incontinent of bladder and 19 residents incontinent of bowel. The facility census was 58. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/08/18. Diagnoses included depressive disorder, Parkinson's disease, encephalopathy, basal cell carcinoma of skin, muscle wasting, mood disorder, insomnia, hypertension, rheumatoid arthritis, vitamin D deficiency and vitamin B deficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact, required the extensive assistance of two staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and was always incontinent urine and frequently incontinent of bowel. Review of the care plan dated 03/28/18 revealed Resident #10 had episodes of bowel incontinence related to cognitive deficit and impaired mobility with an an intervention that included peri care to be provided following episode of bowel incontinence. The care plan updated on 07/08/22 revealed Resident #10 required assistance for activities of daily living (ADL) related to weakness and a diagnoses of Parkinson's disease interventions included for staff to provide assistance to complete ADL tasks, encourage the resident to call for assistance and allow time for the staff to respond, and for staff to provide assistance as needed with bed mobility, transfers, eating and toilet use and the call light was to be kept within reach of the resident. Review of the current physician orders revealed an order dated 09/09/21 for Resident #10 to be turned and repositioned every two hours. Observation on 05/01/23 at 9:03 A.M. revealed a foul odor on Hallway B. The odor became stronger the further one progressed down the hallway. Resident #10 was observed in the room moaning and yelling out. Interview on 05/01/23 at 9:05 A.M. with Resident #10 revealed the resident had been incontinent and needed staff assistance and could not find the call light. Observation at the time of interview revealed the call light was outside the reach of Resident #10 sitting on the wheelchair to the left of the bed. The foul odor noted in the hallway became more pungent upon entering Resident #10's room. Observation of incontinence care for Resident #10 on 05/01/23 at 9:28 A.M. performed by State Tested Nursing Assistants (STNA) #315 and STNA #331 revealed the bedding for Resident #10 was saturated. A large dried brown area was noted on the bottom sheet and surrounded Resident #10 from the resident's shoulders to knees. Resident #10 had a dark brown substance down the legs, between the legs and in the groin and a dried dark substance on their stomach. Resident #10 was cleansed from the front to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 6 of 12 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 05/04/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the back, rolled onto the right side, with additional skin care provided to remove brown substances. STNA #357 entered the room at 9:34 A.M. to assist with transferring the resident. During the continued observation Resident #10 was assisted to a standing position by STNA #357 and STNA #331, at which time a brown soft substance was observed dripping from Resident #10's buttocks, down the resident's legs and onto the floor. STNA #315 cleansed the skin of Resident #10 and wrapped the resident in a sheet while STNA #357 and STNA #331 assisted Resident #10 onto a wheeled shower chair. STNA #331 assisted Resident #10 into the shower. STNA #315 removed the linen from Resident #10's bed and cleansed the mattress with disposable wipes. Interview on 05/01/23 at 9:40 A.M., STNA #315 stated care had not been provided to Resident #10 since the start of the shift at 6:00 A.M. Interview on 05/01/23 at 9:40 A.M. with STNA #331 verified Resident #10 was saturated in feces and further stated no care had been provided to Resident #10 since the beginning of the shift at 6:00 A.M. Interview on 05/01/23 at 9:40 with STNA #357 verified no care had been provided to Resident #10 since the beginning of the shift at 6:00 A.M. Additional observation on 05/02/23 at 8:16 A.M. of Resident #10 laying in bed with a brown half moon shape of brown discoloration to the bottom sheet. The brown discoloration extended off side of the mattress and was visible from the hallway. A foul odor was noted. Interview with STNA #315 on 05/02/23 at 8:16 A.M. verified the brown discoloration of the sheets and the foul odor. STNA #315 stated care had not been provided since the beginning of the shift at 6:00 A.M. Review of the facility policy titled Activities of Daily Living, Supporting, dated March 2018, stated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the facility policy titled Perineal Care, dated February 2018, stated care is provided for cleanliness and resident comfort, to prevent infections and skin irritation, and to observe the resident's skin condition. The supervisor is to be notified if the resident refused perineal care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 7 of 12 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 05/04/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure oxygen supplies were dated when initiated. This affected one resident (#20) of two residents reviewed for oxygen therapy. The facility census was 58. Residents Affected - Few Findings Include: Review of Resident #20's medical record revealed an admission date of 10/23/20. Diagnoses included cognitive communication deficit, personal history of COVID-19, peripheral vascular disease, heart disease, anxiety disorder, psychosis, major depressive disorder, and paranoid schizophrenia. Review of Resident #20's Minimum Data Set (MDS) 04/09/23 revealed Resident #20's cognitive skills were moderately impaired. Resident #20 was receiving oxygen therapy at the time of the review. Review of Resident #20's physician orders revealed an order dated 04/24/23 for oxygen at zero to five liters via nasal cannula related to shortness of breath and hypoxia. May titrate oxygen settings to lowest oxygen to maintain oxygen saturation greater than 90%. An order dated 04/30/23 included to change oxygen tubing every Sunday on night shift. Observation on 05/01/23 at 9:30 A.M. of Resident #20's oxygen tubing and humidifier found it undated as to when it was last changed. The tubing was noted to be long. Interview on 05/01/23 at 9:32 A.M. with Resident #20 stated she was not sure when the last time her tubing was changed. She stated she moves herself around the room and verified her tubing was long and dragged around on the floor. Interview on 05/01/23 at 9:33 A.M. with Licensed Practical Nurse (LPN) #340 verified Resident #20's oxygen tubing and humidifier were not dated. LPN #340 reported Resident #20's oxygen tubing was supposed to be changed every Sunday and the date was to be put on the tubing to show when it was changed. Observation on 05/02/23 at 3:00 P.M. found Resident #20's oxygen tubing and humidifier continued to be undated. Resident #20 was observed walking with her walker and rolling over her tubing and dragging it around on the floor. Interview on 05/02/23 at 3:02 P.M. with LPN #340 verified Resident #20's oxygen tubing and humidifier continued to be undated and Resident #20 continued to roll over it with her walker and drag it around on the floor. LPN #340 stated the tubing was most likely changed on Sunday. Observation on 05/03/23 at 8:28 A.M. of Resident #20 found her lying in bed. Her oxygen was connected and continued to not be dated or labeled. Observation on 05/04/23 at 11:01 A.M. of Resident #20 found her lying sideways in her bed. Resident #20 was dressed and her oxygen was connected. Her tubing and humidifier continued to be undated. Review of the facility policy titled Oxygen Administration, revised 04/14/20, revealed the staff were to assure the humidifier and oxygen tubing was changed every seven days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 8 of 12 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 05/04/2023 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 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 resident interview, observation, staff interview and completion of the a lunch meal test tray revealed the facility failed to ensure residents received palatable food that was properly cooked. This affected three residents (#28, #38, and #22) of four residents reviewed for food palatability. The facility census was 58. Residents Affected - Few Findings include: 1. Review of Resident #28's medical record revealed an admission date of 07/20/18. Diagnoses included dysphagia, Parkinson's disease, cognitive communication deficit, type II diabetes, dementia, morbid obesity, schizoaffective disorder, mood disorder, major depressive disorder, impulse disorder, and osteoarthritis. Review of Resident #28's Minimum Data Set (MDS) assessment, dated 04/03/23, revealed Resident #28 was moderately cognitive impaired. Resident #28 received a mechanically altered diet at the time of the review. Review of Resident #28's care plan revised 02/01/23 revealed potential for nutritional risk related to therapeutic and mechanically altered diet. Review of Resident #28's physician orders revealed an order dated 01/31/23 for a controlled carbohydrate diet with ground meat texture and thin consistency. Interview on 05/01/23 at 9:52 A.M. with Resident #28 revealed he was alert and aware. Resident #28 reported about three times a week the food was not good. He reported at times the vegetables and fruits were not cooked well enough and they were too hard for him to chew. 2. Review of Resident #38's medical record revealed an admission date of 02/13/23. Diagnoses included dysphagia, type II diabetes, and cognitive communication deficit. Review of Resident #38's MDS assessment, dated 02/20/23, revealed Resident #38 was cognitively intact. Resident #38 received a mechanically altered therapeutic diet at the time of the review. Review of Resident #38's care plan revised 03/01/23 revealed supports and interventions for nutritional risk related to mechanically altered diet texture and significant weight gain. Review of Resident #38's dietary evaluation dated 10/24/22 revealed Resident #38 was to be on a regular diet with dysphagia advanced consistency (mechanical soft) and thin liquids. Review of Resident #38's physician orders revealed an order dated 04/27/23 and discontinued 05/02/23 for consistent carbohydrate diet, mechanical soft texture and thin consistency. An order dated 05/02/23 for a consistent carbohydrate diet with regular texture and thin consistency. Observation on 05/01/23 at 11:46 A.M. found Resident #38 was seated in the main dining room and was provided his lunch meal. Resident #38 was provided the chicken pot pie with corn and carrots in it and after taking a couple bites Resident #38 was observed telling the staff in the dining room that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 9 of 12 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 05/04/2023 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the carrots were too hard and he was not able to chew them. The staff was observed verifying with Resident #38 the carrots were too hard for Resident #38 and they offered to get him something else. The noon meal was observed to consist of either chicken pot pie with corn or chicken pot pie without corn, both of which contained carrots. Completion of a test tray on 05/01/23 at 11:53 A.M., which included both the chicken pot pie with the corn and carrots found the carrots in the chicken pot pie were firm and slightly under done. It was noted the carrots would be hard to chew for someone on a modified texture diet. 3. Review of the medical record for Resident #22 revealed an admission date of 12/10/15 with diagnoses of vitamin deficiency and type 2 diabetes mellitus. Review of the quarterly MDS assessment, dated 04/04/23, revealed Resident #22 had slightly impaired cognition and required supervision with setup help only for eating. Review of the physician's order dated 08/10/21 revealed Resident #22 was on a controlled carbohydrate diet with regular textures and thin liquids. Interview on 05/01/23 at 9:42 A.M. with Resident #22 revealed he did not like the food because it had little taste. Completion of a test tray on 05/01/23 at 11:53 A.M., which included both the chicken pot pie with the corn and the chicken pot pie without the corn, found both pot pies to be very warm but underseasoned and bland tasting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 10 of 12 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 05/04/2023 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of the infection surveillance log, and review of facility policy, the facility failed to ensure residents receiving an ongoing prophylactic antibiotic had a reason for continued use. This affected one (Resident #2) of six residents reviewed for unnecessary medications. The facility census was 58. Residents Affected - Few Findings include: Review of Resident #2's medical record revealed an admission date of 07/03/18 and a readmission date of 03/14/22. Diagnoses included neuromuscular dysfunction of the bladder, history of COVID-19, bipolar disorder, morbid obesity, retention of urine, intellectual disabilities, mood disorder, anxiety disorder, schizoaffective disorder, and major depressive disorder. Review of Resident #2's Minimum Data Set (MDS) assessment, dated 01/20/23, revealed Resident #2 was moderately cognitively impaired. Review of Resident #2's care plan revised 05/02/23 revealed supports and interventions for potential for urinary tract infections and indwelling Foley catheter related to urinary retention. Interventions for potential for urinary tract infections included administering medications as ordered, monitor for signs and symptoms of urinary tract infections, and to continue on antibiotic therapy as ordered. Review of Resident #2's physician orders revealed a current order initiated on 12/18/21 for the antibiotic trimethroprim 50 milligrams (mg) one time a day for personal history of urinary tract infection. Review of Resident #2's Medication Administration Record (MAR) for February 2023, March 2023, April 2023, and May 2023 revealed Resident #2 received the antibiotic trimethoprim 50 mg daily. Review of Resident #2's Pharmacy Recommendations revealed on 03/08/22 the pharmacist recommended the physician consider discontinuing the trimethoprim 100 mg one time daily for urinary tract infection (UTI) prophylaxis due to the urine culture dated 01/12/22 showing Staphylococcus aureus was resistant to trimethoprim. The physician responded on 03/29/22 disagreeing with the recommendation stating it would prevent other pathogens. No further reasoning for continued use was found. Review of the Infection Prevention and Antibiotic Stewardship log for February 2023, March 2023, and April 2023 revealed Resident #2 was on trimethoprim from 12/19/21 indefinitely. Review of Resident #2's 12/16/22 urinalysis results revealed Resident #2 had a urinary tract infection with the organism enterococcus faecalis that was sensitive to ampicillin, nitrofurantoin, penicillin, tetracycline, and vancomycin. Review of Resident #2's 03/15/23 urinalysis results stated mixed skin flora was found and no sensitivity was completed. Review of Resident #2's 04/26/23 urinalysis completed at the hospital revealed Resident #2 had no urinary tract infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 11 of 12 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 05/04/2023 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #2's Infection Screening Evaluations dated 10/20/22, 12/15/22, 02/13/23, 03/15/23 and 04/21/23 revealed Resident #2 had no infectious disease concerns. Resident #2 had no active diagnosis of infection at the time of the reviews. Resident #2 also did not have any signs or symptoms of infection and did not meet infection criteria. Interview on 05/04/23 at 1:49 P.M., Infection Preventionist (IP) #356 revealed she was not sure why Resident #2 was still receiving trimethoprim. IP #356 verified there was no reason for the continued use of trimethoprim as Resident #2 had no history of infectious disease involvement, no signs or symptoms of of infection and no current monitoring for urinary tract infections (UTI) signs and symptoms being completed. IP #356 verified all Resident #2's infection screening evaluations reflected no infections. IP #356 reported all prophylactic antibiotic used was reviewed at the Quality Assurance meetings. IP #356 reported the physician discontinued all the other prophylactic antibiotics and she was not sure why Resident #2's were not discontinued. Interview on 05/04/23 with Registered Nurse (RN) #365 revealed Resident #2 last saw the urologist in November of 2021 and was scheduled to see the urologist again 05/11/23 at 10:40 A.M. RN #365 reported she spoke with Resident #2's physician and he indicated he wanted to continue the use of the prophylactic antibiotic for Resident #2. RN #365 verified there was no written documentation supporting the continued justification of need. Review of the facility policy titled Antibiotic Stewardship, revised October 2018, revealed prescribers were to document the dose, duration, and indication for all antibiotic prescriptions. The facility was to track, monitor antibiotic prescribing, use, and resistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365570 If continuation sheet Page 12 of 12