Inspection·July 30, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and facility policy, the facility failed to ensure a resident's bathroom was adequately maintained and in a sanitary condition. This affected one (#29) of four residents reviewed. The facility census was 53. Findings include: Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses included unspecified dementia severe with agitation, chronic kidney disease, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, schizophrenia, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required supervision assistance with toileting and was frequently incontinent of bowel and bladder. Review of the most recent care plan revealed Resident #29 had potential for bowel and bladder incontinence, frequently or almost always urinates on the floor in the bathroom, misses the toilet or does not even attempt to sit on the toilet to urinate and urine goes all over the floor. One intervention states for staff to frequently check bathroom floor for urine on the floor. Observation on 07/29/24 at 11:00 A.M. revealed a strong malodorous odor from the hallway. Upon further investigation Resident #29's resident bathroom was observed to have a substantial amount of liquid on the floor. The tile floor was stained, discolored, and warped. The area around the toilet was black in color and the wood like bathroom cabinet appeared to be warped on the bottom left side. Interview on 07/29/24 at 11:21 A.M. with Registered Nurse (RN) #202 verified Resident #29's bathroom was unclean, unsanitary, and not in a good state of repair. RN #202 reported Resident #29 often urinated on the bathroom floor. Review of policy, Quality of Life- Homelike Environment, revised May 2017, verified the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a homelike setting including a clean, sanitary, and orderly environment. This deficiency represents non-compliance investigated under Complaint Number OH00155509. 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 07/30/2024 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)