Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
resident financial record review, staff interview, and facility policy review, the facility failed to adequately
notify residents and/or representative of the possibility of lost Medicaid eligibility for reaching and exceeding
the maximum amount within their resident funds accounts. This affected two (Resident #34 and Resident
#48) of six residents whose financial records were reviewed. The census was 44.
Residents Affected - Few
Findings include:
1. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses were quadriplegia, other recurrent depressive disorders, osteoarthritis, aphasia, epilepsy,
glaucoma, and car driver injured in collision, with other type car in traffic accident. Review of the Minimum
Data Set (MDS) 3.0 assessment, dated 04/01/22, revealed Resident #34 was deemed to have a severe
cognitive impairment.
Review of Resident #34's financial records revealed the following quarterly balances: Second quarter 2021
was $5369.83, third quarter 2021 was $5402.63, fourth quarter 2021 was $5614.40, and first quarter 2022
was $7340.00; all of which were over the $2000 limit allowed by Medicaid. From 05/28/21 to 04/29/22, a
letter was sent by the facility to Resident #34 representative that stated, This letter is to notify you that your
current resident fund is within $200 or exceeding what is allowable under Medical assistance. Please
contact your social worker within the next seven days to discuss ways to assure continuance of Medicaid
benefits. There was no documentation to support Resident #34's representative called to discuss the funds
exceeding the Medicaid limit, nor any documentation to support the facility provided more detailed
information to Resident #34's representative about the possibility of losing Medicaid benefits due to his
resident funds amount.
2. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses were chronic obstructive pulmonary disease, dysphagia, mild cognitive impairment, acute
kidney failure, hypertensive heart disease, alcohol abuse, hyperlipidemia, and cerebral infarction. Review of
the MDS 3.0 assessment, dated 04/01/22, revealed Resident #48 was deemed to have a severe cognitive
impairment.
Review of Resident #48's financial records revealed the following quarterly balances: second quarter 2021
was $3909.41, third quarter 2021 was $2005.46, fourth quarter 2021 was $2099.28, and first quart 2022
was $2205.17. From 05/28/21 to 04/26/22, a letter was sent by the facility to Resident #48 that stated, This
letter is to notify you that your current resident fund is within $200 or exceeding what is allowable under
Medical assistance. Please contact your social worker within the next seven days to discuss ways to assure
continuance of Medicaid benefits. There was no documentation to
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
support Resident #48 had a meeting with the facility to discuss the funds exceeding the Medicaid limit, nor
any documentation to support the facility provided more detailed information to Resident #48 about the
possibility of losing Medicaid benefits due to his resident funds amount.
Interview with the Administrator on 05/12/22 at 11:45 A.M. confirmed both Resident #34 and Resident #48
had resident fund limits over the Medicaid limit. The Administrator confirmed the information that was listed
within spend down notices, sent to the residents/representative, was all that was sent to them. The
Administrator confirmed they had spoke to both residents/representatives for multiple months, but they had
not developed a plan in which to spend the money to a level that ensured each resident's Medicaid benefits
were not canceled.
Review of the facility Resident Personal Funds policy, dated September 2017, revealed Medicaid recipients
were subject to strict resource limits to remain eligible for Medicaid program. Therefore, the facility would
notify each resident that received Medicaid when the amount in the resident's account reached $200 less
than the Medicaid resource limit to ensure no loss of eligibility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to revise Pre-admission Screening and Resident
Review (PASRR) records when the initial PASRR document was not correct. This affected two (Resident #7
and Resident #29) of three residents reviewed for PASRR. The census was 44.
Findings include:
1. Medical record review revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses were end
stage renal disease, muscle weakness, difficulty walking, cognitive communication deficit, major depressive
disorder, schizoaffective disorder, anxiety disorder (12/13/21), muscle wasting and atrophy, dementia,
hypothyroidism, hypertension, type II diabetes, chronic kidney disease (stage IV), schizophrenia, mild
intellectual disabilities (10/17/20), generalized anxiety disorder (10/17/20), and unspecified protein-calorie
malnutrition. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment, dated 04/15/22, revealed
Resident #7 was deemed to have a significant cognitive impairment.
Review of Resident #7's PASRR application, dated 12/14/21, revealed in section E, the documented mental
health diagnosis indicated Resident #7 had schizophrenia; anxiety was not indicated within that section as
a diagnosis. Also, under section F, the PASRR document indicated Resident #7 did not have an intellectual
disability. Review of Resident #7's current face sheet and diagnoses list featured that Resident #7 had the
diagnoses of generalized anxiety disorder and mild intellectual disabilities at the time of admission on
[DATE]. Also, Resident #7 had the diagnosis of generalized anxiety disorder added to her list on 12/13/21.
Finally, review of Resident #7's MDS assessment, section I, the diagnoses of anxiety disorder and mild
intellectual disabilities were listed. There was no documentation of a PASRR document revised after
12/14/21 to reflect all Resident #7's current diagnoses.
2. Medical record review revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses were
multiple sclerosis, asthma, pain in hip, generalized anxiety disorder (07/05/18), anxiety disorder (10/28/19),
post traumatic stress disorder (07/05/18), major depressive disorder (07/05/18), hyperlipidemia, and
trigeminal neuralgia. Review of Resident #29's MDS 3.0 assessment, dated 04/22/22, revealed Resident
#29 was deemed to be cognitively intact.
Review of Resident #29's PASRR application, dated 04/15/22, revealed in section E, she had no mental
health diagnoses. Review of Resident #29's current face sheet and diagnoses list featured that Resident
#29 had the diagnoses of generalized anxiety disorder, post traumatic stress disorder, major depressive
disorder, and anxiety disorder all present upon admission to the facility; they were not indicated on her
PASRR document. Finally, review of Resident #29's MDS assessment, section I, indicated all the above
diagnoses that were not listed on the PASRR document. There was no documentation of a PASRR
document revised after 04/15/22 to reflect all Resident #29's diagnoses.
Interview with the Director of Nursing (DON) on 05/11/22 at 1:35 P.M. confirmed the PASRR documents
presented were the most recent updates. The DON indicated they were going through all resident PASRR
documents to ensure they were up to date. The DON confirmed the diagnoses and information that should
have been on the PASRR, were not on them for Resident #7 and Resident #29.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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 0646
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the appropriate authorities when residents with MD or ID services has a significant change in
condition.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to inform the state mental health agency of a
significant change in Pre-admission Screening and Resident Review (PASRR) records. This affected two
(Resident #7 and Resident #29) of three residents reviewed for PASRR. The census was 44.
Findings include:
1. Medical record review revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses were end
stage renal disease, muscle weakness, difficulty walking, cognitive communication deficit, major depressive
disorder, schizoaffective disorder, anxiety disorder (12/13/21), muscle wasting and atrophy, dementia,
hypothyroidism, hypertension, type II diabetes, chronic kidney disease (stage IV), schizophrenia, mild
intellectual disabilities (10/17/20), generalized anxiety disorder (10/17/20), and unspecified protein-calorie
malnutrition. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment, dated 04/15/22, revealed
Resident #7 was deemed to have a significant cognitive impairment.
Review of Resident #7's PASRR application, dated 12/14/21, revealed in section E, her documented mental
health diagnoses indicated she only had schizophrenia; anxiety was not indicated within that section as a
diagnosis. Also, under section F, the PASRR document indicated she did not have an intellectual disability.
Review of Resident #7's current face sheet and diagnoses list featured that she had the diagnoses of
generalized anxiety disorder and mild intellectual disabilities at the time of admission on [DATE]. Also, she
had the diagnosis of generalized anxiety disorder added to her list on 12/13/21. Finally, review of Resident
#7's MDS assessment, section I, revealed the diagnoses of anxiety disorder and mild intellectual disabilities
were listed. There was no documentation to support the facility contacted the state mental health agency at
the time the significant change was identified.
2. Medical record review revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses were
multiple sclerosis, asthma, pain in hip, generalized anxiety disorder (07/05/18), anxiety disorder (10/28/19),
post traumatic stress disorder (07/05/18), major depressive disorder (07/05/18), hyperlipidemia, and
trigeminal neuralgia. Review of Resident #29's MDS 3.0 assessment, dated 04/22/22, revealed Resident
#29 was deemed to be cognitively intact.
Review of Resident #29's PASRR application, dated 04/15/22, revealed in section E, Resident #29 had no
mental health diagnoses. Review of Resident #29's current face sheet and diagnoses list featured that
Resident #29 had the diagnoses of generalized anxiety disorder, post traumatic stress disorder, major
depressive disorder, and anxiety disorder all present upon admission to the facility; they were not indicated
on her PASRR document. Finally, review of Resident #29's MDS assessment, section I, indicated all the
above diagnoses that were not listed on the PASRR document. There was no documentation to support the
facility contacted the state mental health agency at the time the significant change was identified.
Interview with the Director of Nursing (DON) on 05/11/22 at 1:35 P.M. confirmed the PASRR documents
presented were the most recent updates. The DON indicated they were going through all resident PASRR
documents to ensure they were up to date. The DON confirmed the diagnoses and information that should
have been on the PASRR, were not on them for Resident #7 and Resident #29. The DON also confirmed
there was nothing to support the state mental health agency was notified of the significant
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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 0646
changes.
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:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review and review of the facility policy, the facility failed to identify and monitor
bruises for Resident #27 in a timely manner. This affected one of four residents reviewed for non pressure
skin impairment. The facility census was 45.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #27 revealed an admission date of 10/12/21 with diagnoses
including chronic obstructive pulmonary disorder, osteoarthritis, malignant neoplasm, and history of
thrombus. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #27 was
cognitively intact and required extensive assistance of two persons for activities of daily living. Resident #27
had no skin impairments noted.
Review of the plan of care dated 04/18/22 revealed Resident #27 had bruising noted throughout her skin
due to bumping self against various items in her room. The interventions included to inspect skin during
routine daily care, and skin assessment as ordered.
Observations on 05/09/22 at 10:42 A.M. , and on 05/11/22 at 11:53 A.M. revealed Resident #27 had a
nickel sized blue bruise noted to top of right hand and a small deep purple bruise to left forearm.
Review of Resident #27's Treatment Administration Record (TAR) for 05/22 revealed no documentation of
monitoring for the bruises noted to the top of right hand and left forearm. However, the nurses completed a
weekly skin assessment every Friday.
Review of Resident #27's nursing progress notes from 05/01/22 through 05/11/22 revealed no
documentation related to the bruises noted to the top of the right hand and left forearm. The weekly skin
assessment, last completed on 05/06/22, did not indicate any bruising to Resident #27's skin.
An interview on 05/09/22 at 10:42 A.M. with Resident #27 revealed she was not sure how she received the
bruises, but she took a blood thinner medication and bruised easily.
An interview on 05/11/22 at 8:32 A.M. with the Director of Nursing (DON) at Resident #27's bedside,
confirmed Resident #27 had a blue bruise noted to the top of her right hand and a small deep purple bruise
to left forearm. The DON indicated the procedure upon finding a bruise on a resident was to complete an
incident report when notified of the bruise, investigate how it happened, document findings and monitor
until resolved. The DON said she would initiate an incident report at this time and confirmed the bruises
were not documented, or monitored in a timely manner.
Review of the facility policy titled Accident/Incident Reporting and Tracking, dated 04/02, revealed if an
incident or accident involved a resident and resulted in a bruise, the area was to be recorded on the non
decubitus skin sheet for weekly assessment until resolved.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, record review and facility policy review, the facility failed to ensure a palm
guard was offered and passive range of motion was completed for Resident #43. This affected one of three
residents reviewed for range of motion. The facility census was 45.
Findings include:
Review of the medical record for Resident #43 revealed an admission date of 06/15/19 with diagnoses
including Parkinson's disease, muscle wasting and atrophy. Review of the quarterly Minimum Data Set
(MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact, required assistance with
activities of daily living, and had impaired range of motion to one side of upper extremities.
Review of the plan of care dated 03/03/22 revealed Resident #43 had a contracture of the left hand and
refused therapy, the brace, a carrot, and fingernail care. Resident #43 would at times accept cleaning of the
hand and put tissues in the hand. Interventions included to report pain to the nurse and therapy restorative
nursing to evaluate and treat as needed
Review of the therapy referral for restorative nursing beginning 04/19/22 revealed Resident #43 may benefit
from a left palm guard. Apply the palm guard to the left hand daily and wear time was at the resident's
discretion. Range of motion to be provided by the staff with daily care.
Review of the Treatment Administration Record (TAR) for 04/22 and 05/22 revealed no order for a palm
guard to Resident #43's left hand.
Review of the nursing progress notes for 04/01/22 through 05/11/22 revealed no documentation of Resident
#43 refusing to wear a palm guard to her left hand.
Review of the State Tested Nursing Assistant (STNA) task of restorative care splint program and range of
motion for the past 30 days revealed no documentation or evidence the task was completed or attempted
for Resident #43.
Observations on 05/09/22 at 11:37 A.M., on 05/10/22 at 10:24 P.M. and at 1:21 P.M., and 05/11/22 at 2:37
P.M. revealed Resident #43's left hand was contracted in a closed position. Resident #43 did not have a
palm guard or any other device in her left hand.
An interview on 05/10/22 at 1:21 P.M. with Resident #43 revealed she did not receive assistance from the
staff with a brace or device of any kind for her left hand.
An interview on 05/11/22 at 3:37 P.M. with STNA #111 revealed Resident #43 often refused the palm guard
to her left hand. STNA #111 said restorative care was to document the tasks section of the resident's
record along with any refusals of care.
An interview on 05/12/22 at 9:02 A.M. with the Director of Nursing (DON) revealed Resident #43 had a
palm guard (confirmed) in her room, and confirmed there was not any documentation related to the
restorative program to apply the palm guard or refusing to allow the staff to apply the palm guard.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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 0688
The Occupational Therapist was unavailable for interview.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's undated policy titled Range of Motion revealed a resident with a contracture (limited
joint motion) would be assessed and a specific program would be developed based upon the resident
assessment.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to implement pharmacy medication regimen
review recommendations approved by the physician in a timely manner for Resident #45. This affected one
(Resident #45) of five residents whose pharmacy recommendations were reviewed. The census was 44.
Findings include:
Medical record review revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses were
congestive heart failure, morbid obesity, difficulty walking, sleep apnea, type II diabetes, encephalopathy,
major depressive disorder, myocardial infarction, anxiety disorder, acute and chronic respiratory failure,
Alzheimer's disease, anemia, osteoarthritis, atherosclerotic heart disease, hypertension, and weakness.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/23/22, revealed Resident #45 was
deemed cognitively intact.
Review of Resident #45's pharmacy recommendation, dated 12/01/21, revealed a recommendation for the
physician to review the quantity and frequency of ferrous sulfate. The ferrous sulfate was currently ordered
at 325 milligrams (mg) twice daily. The physician agreed with the recommendation and changed the order
for ferrous sulfate to 325 mg once daily. This was written and signed on 12/10/22. Review of the pharmacy
recommendation, dated 02/01/22, revealed the pharmacy made the same recommendations for ferrous
sulfate. The physician agreed again and made the same change, ferrous sulfate 325 mg once daily.
Review of Resident #45's Medication Administration Records (MAR), dated December 2021 to February
2022, confirmed the pharmacy recommendation that was confirmed by the physician was not changed from
12/10/21 to 02/10/22.
Review of Resident #45's pharmacy recommendation, dated 12/01/21, revealed a recommendation the
physician define a pain scale for as needed pain medication; Tylenol 325 mg and Percocet 5/325 mg. The
physician did not indicate whether there was an agreement/disagreement with the recommendation and
defined the parameters as followed: Tylenol 325 mg for pain levels 1 through 3 and Percocet 5/325 mg for
pain levels 4 through 10. This was written and signed on 12/10/22. Review of the pharmacy
recommendation, dated 02/01/22, revealed the pharmacy made the same recommendations for defining
the pain scale for as needed Percocet and Tylenol. The physician agreed and a different pain scale than
what was issued on 12/10/22; Tylenol 325 mg for pain levels 3 through 6 and Percocet 5/325 mg for pain
levels 7 through 10
Review of Resident #45's MAR, dated December 2021 to February 2022, confirmed the pharmacy
recommendation that was confirmed by the physician was not changed from 12/10/21 to 02/10/22.
Interview with Director of Nursing (DON) on 05/10/22 at 4:30 P.M. revealed Resident #45's pharmacy
recommendations were not entered into the electronic records and started after they were written/approved
by the physician in December 2021. The DON confirmed they should have been, which is why the
pharmacy reissued the recommendations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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** 3. Review of
the medical record for Resident #27 revealed an admission date of 10/12/21 with diagnoses including
osteoarthritis, weakness and left knee pain.
Residents Affected - Few
Review of the plan of care updated 11/03/21 indicated Resident #27 had alteration in comfort related to
chronic pain. Interventions included medications as ordered to manage pain, monitor for side effects of pain
medication, monitor for effectiveness of interventions, use the pain scale as reported by resident and pain
assessment per facility policy.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #27 was
cognitively intact and required extensive assistance with activities of daily living, had impaired range of
motion to bilateral lower extremities and occasional mild pain.
Review of the 05/22 physician orders revealed Resident #27 was ordered Percocet 5-325 milligrams (mg)
by mouth every four hours as needed for pain and Tylenol 325 mg by mouth give two tablets every four
hours as needed for pain without parameters of level pain before administering.
Review of the Medication Administration Record (MAR) for 04/22 and 05/22 revealed Resident #27
received Percocet 5-325 mg by mouth as needed for pain several times with a pain level of one to eight.
Resident #27 did not receive any doses of Tylenol. The MAR did not indicate the pain level to administer the
Percocet or the Tylenol.
An interview on 05/12/22 at 9:50 A.M. with Registered Nurse (RN) #144 revealed the nurse completed a
pain assessment daily on each resident. RN #144 said Resident #27 would ask specifically for the Percocet
instead of the Tylenol. RN #144 confirmed the orders did not have parameters to determine what
medication to administer with a level of pain.
Review of the undated facility policy titled Pain Management revealed the policy did not address pain level
parameters with as needed pain medications.
Based on medical record review, staff interview, and policy review, the facility failed have proper parameters
for as needed pain medications for Residents #45 and #27, and failed to provide medications as written per
the physician for Resident #45. This affected two (Resident #45 and Resident #27) of five residents
reviewed for unnecessary medications. The census was 44.
Findings include:
1. Medical record review revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses were
congestive heart failure, morbid obesity, difficulty walking, sleep apnea, type II diabetes, encephalopathy,
major depressive disorder, myocardial infarction, anxiety disorder, acute and chronic respiratory failure,
Alzheimer's disease, anemia, osteoarthritis, atherosclerotic heart disease, hypertension, and weakness.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/23/22, revealed Resident #45 was
deemed cognitively intact.
Review of Resident #45's pharmacy recommendation, dated 12/01/21, revealed the pharmacy
recommended the physician review the quantity and frequency of ferrous sulfate. It was currently ordered at
325 milligrams (mg) twice daily. The physician agreed with the recommendation and changed the order for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
ferrous sulfate to 325 mg once daily. This was written and signed on 12/10/22. Then, a pharmacy
recommendation, dated 02/01/22, revealed the pharmacy made the same recommendations for ferrous
sulfate. The physician agreed again and made the same change, ferrous sulfate 325 mg once daily.
Review of Resident #45's Medication Administration Records (MAR), dated December 2021 to February
2022, confirmed the pharmacy recommendation that was confirmed by the physician was not changed from
12/10/21 to 02/10/22. Therefore, the facility administered ferrous sulfate 325 mg twice daily to Resident #45
during that timeframe, when it should have been once daily.
2. Review of Resident #45's pharmacy recommendation, dated 12/01/21, revealed the pharmacy
recommended the physician define a pain scale for as needed pain medication; Tylenol 325 mg and
Percocet 5/325 mg. The physician did not indicate whether there was an agreement/disagreement with the
recommendation and defined the parameters as followed: Tylenol 325 mg for pain levels 1 through 3 and
Percocet 5/325 mg for pain levels 4 through 10. This was written and signed on 12/10/22. Then, a pharmacy
recommendation, dated 02/01/22, revealed the pharmacy made the same recommendations for defining
the pain scale for as needed Percocet and Tylenol. The physician agreed and a different pain scale than
what was issued on 12/10/22; Tylenol 325 mg for pain levels 3 through 6 and Percocet 5/325 mg for pain
levels 7 through 10.
Review of Resident #45's Medication Administration Records (MAR), dated December 2021 to February
2022, confirmed the pharmacy recommendation that was confirmed by the physician was not changed from
12/10/21 to 02/10/22; therefore Percocet 5/325 mg (as needed) was given numerous times per day, without
having proper pain parameters in place. Tylenol was not given during this timeframe.
Review of Resident #45's MAR, dated February 2022, revealed Percocet 5/325 mg was given outside the
written pain parameters (pain level 7 to 10) 12 times. Also, Tylenol 325 mg was given outside the written
pain parameters (pain level 1 to 3) one time.
Interview with Director of Nursing (DON) on 05/12/22 at 11:19 A.M. confirmed pain medications given
outside parameters or when pain parameters had not been added to the MAR. She also confirmed the
ferrous sulfate 325 mg was given twice daily from 12/10/22 to 02/10/22, when the physician had recorded
on the pharmacy recommendation to lower the dosage to once daily on 12/10/21.
Review of undated facility Pain Management policy revealed a pain assessment should begin with resident
self-reporting. Offer non-pharmacological interventions prior to administering pain medications. Pain
assessments should occur at each new report of pain (with as needed pain medication administration),
change in condition, and pain medication change, and if as needed medications prescribed, chart
medication on MAR; note reason and response.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
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
365588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Valley Skilled Nursing and Rehabilitation
25675 East Main Street
Coolville, OH 45723
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, staff interview, and facility policy review, the facility failed to store and date food in a
safe manner. This had the potential to affect 44 of 44 residents in the facility.
Residents Affected - Many
Findings include:
Observations on 05/09/22 from 8:25 A.M. to 8:35 A.M. revealed the following items were open and undated
as to when they were opened or when they should be discarded, in the facility freezer: chicken wings,
country friend steak, chicken patties, and sausage patties.
Interview with Dietary Manager #138 on 05/09/22 at approximately 8:35 A.M. confirmed the items listed
above were opened and undated. She stated she was not aware that items within the freezer had to be
dated with either the date they were opened or the date in which they should be discarded.
Review of facility Food Storage policy, dated March 2022, revealed all foods should be covered, labeled,
and dated. All foods would be checked to assure that foods would be consumed by their safe used by dates
or discarded.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365588
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F646 - A nursing facility must notify the state mental health authority or state
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the May 12, 2022 survey of ARCADIA VALLEY SKILLED NURSING AND REHABILITATION?
This was a inspection survey of ARCADIA VALLEY SKILLED NURSING AND REHABILITATION on May 12, 2022. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ARCADIA VALLEY SKILLED NURSING AND REHABILITATION on May 12, 2022?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.