Inspection·April 27, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to the facility. The remainder of the admission assessment was completed by Registered Nurse (RN) #44, who was the night shift nurse that worked from 7:00 P.M. on 12/17/22 until 7:00 A.M. on 12/18/22. Her assessment findings indicated the resident was known to have difficulty breathing, labored respirations, inspiratory wheezes throughout her bilateral lungs, lethargy, and skin that was pale/ cool/ and clammy. The assessment indicated that the resident's admission orders were verified by the physician on 12/17/22 at 8:00 P.M. It did not indicate that the physician was notified of the resident's adverse condition at the time of her readmission to the facility. It also did not include a place to document the notification of the resident's responsible party on her condition at the time of her readmission. Further review of Resident #40's progress notes revealed a nurse's note by RN #10 dated 12/17/22 at 6:40 P.M. that indicated the resident returned to the facility from the hospital. The nurse's note indicated the nurse contacted the resident's daughter/ responsible party and reviewed the resident's orders in detail and all were in agreement. The primary care physician was also indicated to be notified. The progress notes did not indicate the resident's physician or daughter was notified of the resident's adverse condition noted upon her return to the facility. The resident's assessment had not been completed at the time that notification was made, as the nurse (RN #44) that completed the physical assessment and documented it in the assessment packet, did not arrive at work until 7:00 P.M. No additional progress notes were documented by RN #44 to indicate she contacted the physician or the resident's responsible party to update them on the resident's adverse condition she noted when she completed the admission assessment. On 04/20/23 at 8:17 A.M., a phone interview with Resident #40's family member revealed she was the resident's responsible party and was the one the facility typically contacted to inform them of the resident's changes in condition or new orders. She denied she was made aware of any changes or adverse conditions involving the resident upon her readmission to the facility on [DATE]. She stated she contacted the facility upon the resident's return to the facility on [DATE] and was told the resident was doing fine. She was not aware the resident was having any difficulty breathing or had any other adverse conditions until they contacted her the morning of 12/18/22, when the resident was found unresponsive. On 04/22/23 at 3:45 P.M., a phone interview with RN #44 revealed she could not recall what part of Resident #40's readmission assessment she completed upon the resident's return from the hospital on [DATE]. She vaguely remembered the resident as it was several months ago. She confirmed she worked on 12/17/22 and came to work at 7:00 P.M. She indicated if the admission packet was signed off by her then she would have been the one to complete the admission assessment. She indicated she would have received report and then would have completed the admission assessment before she started her evening medication pass. She could not recall if the resident had any abnormal findings during her admission assessment and would have to refer to what she documented in the admission assessment. She was informed of what she had documented in her admission assessment pertaining to the resident having difficulty breathing, labored respirations, inspiratory wheezes throughout her bilateral lungs and having pale, cool and clammy skin. She indicated, if that was her assessment, she would have questioned why the hospital sent her back that way. She remembered vaguely the resident did not respond well the following morning and that was when she was sent back out to the hospital or the Director of Nursing (DON) was called. She denied she called the doctor and reviewed the resident's admission orders with him as was documented on the admission packet as having occurred on 12/17/22 at 8:00 P.M. She was not sure, if anyone had called the physician to notify him of the resident's adverse condition upon her return to the facility. She denied she had contacted the physician or the resident's family, after she completed the admission assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 2 of 10 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 04/27/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/24/23 at 9:15 A.M., an interview with Physician #52 revealed Resident #40's name rang a bell, but he did not recall much about her or anything that may have taken place four months ago. He was provided some information on the resident to help refresh his memory, such as why she was sent out to the hospital on [DATE] and her diagnoses when she returned to the facility on [DATE]. He could not recall the facility contacting him about the resident's adverse condition that was noted with her admission assessment the evening of 12/17/22. He stated he had so many nursing homes and took care of a lot of residents that he was not able to recall any specifics that far back. He was then asked if he would have wanted to be notified of the resident's adverse condition upon her return to the facility as was documented in her admission assessment. He stated typically yes he should have been contacted, if a resident was struggling and having any distress upon their re-admission to the facility. On 04/24/23 at 9:35 A.M., an interview with the DON confirmed Resident #40's admission assessment did show that she had signs of respiratory distress (difficulty breathing, labored respirations, inspiratory wheezes throughout her lungs bilaterally) upon her return from the hospital. She acknowledged the documentation in the resident's medical record did not provide documented evidence the physician or the family was made aware of the resident's adverse condition upon her return to the facility. She indicated the admission assessment did indicate that the physician was contacted on 12/17/22 at 8:00 P.M. to verify the admission orders and she would have assumed that meant the nurse also reviewed any abnormal findings she had identified as part of the assessment. She acknowledged the nurse that was present at the time the physician notification was indicated to have been made denied she had spoken with the physician on that evening regarding anything to do with the resident's readmission orders or anything about her condition upon her return. She also acknowledged the physician did not recall anyone notifying him of that and based on the symptoms documented in the assessment they should have. On 04/24/23 at 12:47 P.M., a phone interview with RN #10 revealed she was vaguely familiar with Resident #40. She was not normally on the side of the building where the resident resided on when there. She did not recall working on 12/17/22, when the resident was readmitted to the facility from the hospital. She was not sure what time the resident returned to the facility or what involvement, if any, she had with the admission process. She indicated the vital signs that were obtained at 6:05 P.M. would have been done by the aides at the time the resident arrived at the facility. She was asked if she knew what the resident's condition was, when she returned to the facility. She indicated she did not really recall. She just remembered her not doing well. She was not sure of anything other than what she may have documented in her charting or any conversations she may have had with the resident's responsible party. A review of the facility's Change in Condition/ Notification policy (dated July 2016) revealed it was the policy of the facility to comply with the regulations regarding notification of changes in condition. The facility would immediately or at least within 24 hours inform the resident, consult with the resident's physician, and if known, notify the resident's interested family member when there was a significant change in the resident's physical, mental, or psychosocial status (i.e. deterioration in health in either life threatening conditions or clinical complications), a need to alter treatment significantly (i.e. commence a new form of treatment), or a decision to transfer the resident from the facility. This deficiency represents non-compliance investigated under Master Complaint Number OH00141418 and Complaint Number OH00141416. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 3 of 10 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 04/27/2023 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 medical record review, physician interview, staff interview, and policy review, the facility failed to ensure a resident who was readmitted to the facility from the hospital with adverse medical conditions received the necessary care and services to appropriately treat/ manage her change in condition. This affected one (#40) of three residents reviewed for changes in condition. Residents Affected - Few Findings include: A review of Resident #40's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), Alzheimer's disease, unspecified dementia with agitation, psychotic disorder with delusions, and major depressive disorder. She was hospitalized between 12/12/22 and 12/17/22 where she was diagnosed with metabolic encephalopathy, pneumonia, sepsis, and a Respiratory Syncytial Virus (RSV) infection. A review of Resident #40's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and adequate hearing. She was usually able to make herself understood and was usually able to understand others. Her cognition was moderately impaired. She was known to have hallucinations, delusions, verbal behaviors directed at others, physical behaviors directed at others, other behaviors not directed at others four to six days of the seven day assessment period. She was also known to reject care one to three days of the assessment period. A review of Resident #40's care plans revealed she had a care plan in place for having an alteration in health maintenance related to her diagnoses of COPD, myotonic muscular dystrophy, Alzheimer's disease, psychotic disorder with delusions, hallucinations, anxiety, depression, and anemia. The care plan was initiated on 11/03/22. The interventions included administering aerosol treatments as ordered, monitor for reduced respirations, changes in level of consciousness, and monitor for symptoms of distress and report to the physician. Respiratory symptoms to monitor for included dyspnea (difficulty breathing), cyanosis, cough, confusion, abnormal lung sounds, and use of accessory muscles. A review of a SBAR (Situation, Background, Appearance, and Review) progress note dated 12/12/22 revealed Resident #40 was found with a fixed stare, was drooling, and was unable to follow commands. She was also indicated to have abdominal pain, an altered mental status, decreased food and fluid intake, and was showing possible signs of a stroke. She was transferred to the emergency room for an evaluation. A review of Resident #40's nurses' progress notes revealed she was admitted to the hospital on [DATE], where she remained until 12/17/22. Her diagnoses included metabolic encephalopathy, pneumonia, sepsis (systemic blood infection), and a RSV infection. A hospital Discharge summary dated [DATE] revealed Resident #40 was returning to the facility in stable condition. Her acute problems while hospitalized included sepsis, metabolic encephalopathy, pneumonia, and a RSV infection. A review of Resident #40's admission nursing assessment dated [DATE] revealed the resident returned from the hospital and was readmitted to the facility. The admission packet had been opened at 12:30 P.M. but was not filled out until vital signs were recorded at 6:05 P.M. upon the resident's return to the facility. The remainder of the admission assessment was completed by Registered Nurse (RN) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 4 of 10 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 04/27/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #44, who was the night shift nurse that worked from 7:00 P.M. on 12/17/22 until 7:00 A.M. on 12/18/22. RN #44's assessment findings indicated the resident was known to have difficulty breathing, labored respirations, inspiratory wheezes throughout her bilateral lungs, confusion, lethargy, and skin that was pale/ cool/ and clammy. The assessment indicated that the resident's admission orders were verified by the physician on 12/17/22 at 8:00 P.M. It did not indicate that the physician was notified of the resident's adverse condition at the time of her readmission to the facility. Further review of Resident #40's progress notes revealed a nurse's note by RN #10 dated 12/17/22 at 6:40 P.M. indicated the resident returned to the facility from the hospital. Her primary care physician and the Director of Nursing (DON) was aware of her return. The progress notes did not indicate the resident's physician was notified of the resident's adverse condition noted on the admission assessment that was completed after her return to the facility. The resident's assessment had not been completed at the time that notification was made, as the nurse (RN #44) that completed the admission assessment and documented it in the admission assessment packet, did not arrive at work until 7:00 P.M. No additional progress notes were documented by RN #44 to indicate she contacted the physician after completing the admission assessment to inform him of any adverse conditions noted with the resident upon her return to the facility. A review of Resident #40's medication administration record (MAR) revealed she did not receive her scheduled medications that were ordered to be administered at bedtime. Included in those orders was Formoteral Fumarate Nebulization solution 20 micrograms (mcg)/ 2 milliliters (ml) with directions to inhale one application orally twice a day for COPD. The order originated on 11/03/22. The administration times were set as early morning and at bedtime. The MAR indicated the nurse (RN #10) had initialed the box and added the code of 6 for the administration time for 12/17/22 at bedtime. The legend indicated a 6 meant the resident was hospitalized when the administration was due. She also had an order to receive Albuterol Sulfate Nebulization solution 2.5 milligrams (mg)/ 0.5 ml with directions to inhale one application orally every four hours as needed (PRN) for COPD. That order had been in place since 11/03/22. The MAR did not reflect the resident had been given a dose on a PRN basis upon her return to the facility despite the resident being documented as having difficulty breathing, labored respirations, and inspiratory wheezes throughout her lungs bilaterally. The only medication that was given to the resident as part of her scheduled bedtime medications was Clonazepam (an antianxiety) 0.5 mg by mouth (po) three times a day for anxiety. The directions indicated the medication should be held if the resident was sedated. A PRN dose of Ativan was given on 12/17/22 at 11:41 A.M. for anxiety. A review of Resident #40's medication administration audit report from 12/17/22 through her discharge date on 12/18/22 revealed the resident was given a dose of Formoterol Fumarate Nebulization solution 20 mcg/ 2 ml on 12/18/22 at 3:09 A.M. The dose had been administered by RN #44. Further review of Resident #40's EHR revealed a SBAR note dated 12/18/22 indicated the resident had a change in condition that included an altered mental status, respiratory arrest, and unresponsiveness. Her blood pressure was found to be 54/24 with a pulse rate of 99 beats per minute. Her respirations were 28 and her oxygen saturation was 95% on oxygen at 2 liters per minute per nasal cannula. The resident's appearance was indicated to be unresponsive, labored respirations, flaccid, hypotensive, and inability to obtain manual pulses. An order was given at 7:20 A.M. to send the resident to the nearest ER. A review of Resident #40's hospital records for her transfer to the hospital on [DATE] revealed an emergency department (ED) physician note dated 12/18/22 that indicated the resident was transferred (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 5 of 10 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 04/27/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to the hospital via EMS. Information obtained was from EMS indicated the resident arrived in full arrest. According to EMS, they were called to the nursing facility because the resident was having difficulty with breathing. Upon their arrival, she had agonal respirations and a palpable pulse but was not really responsive. Shortly after placing her in the ambulance, the resident became apneic and lost her pulse. CPR was initiated along with ACLS protocols. The resident was intubated and in route was given multiple rounds of medications prior to her arrival at the ED. Upon her arrival, the Resident #40 had agonal respirations. Her pupils were fixed and dilated. The resident had a palpable pulse without a [NAME] device. With review of the old records, the resident was just discharged from the hospital the day before. She was being treated for what sounded like RSV and possible pneumonia. Blood cultures and urinalysis were negative. The physician had discussed the results of testing with the Resident #40's family. The husband and daughter requested everything to be done at that point. They did not want the resident to be a Do Not Resuscitate (DNR) Comfort Care Arrest (CCA) or a DNR CC (Comfort Care). The clinical impression was cardiorespiratory arrest, septic shock. She was admitted and her condition was poor. A review of Resident #40's History and Physical completed in the hospital on [DATE] revealed the resident had a history of dementia, pulmonary embolism, anxiety and COPD. She presented for evaluation of hypoxia and restlessness while at the nursing home. She was recently discharged on 12/17/22 for toxic encephalopathy, sepsis, and RSV. She was discharged back to the SNF. Her code status was changed to be DNR however they seem to have been rescinded and the Resident #40 was made a full code. The Resident #40 had a cardiac arrest upon transfer to ED. She was transferred to the ICU where she lost her pulse upon arrival and CPR was started. They discussed with the family about multiple rounds of CPR being attempted and that the resident would not survive that hospitalization given the multiple comorbid conditions and her extensive need for CPR in repetitive occasions. The family then expressed their wishes to not do CPR again and to allow a natural death. The diagnosis was cardiac arrest with the etiology likely being hypoxic, severe metabolic acidosis. Her pupils were already fixed and dilated. The resident expired in the hospital at 12:25 P.M. Her acute problems included pneumonia, sepsis, metabolic encephalopathy, RSV infection, cardiac arrest and acute respiratory failure. On 04/22/23 at 3:45 P.M., a phone interview with RN #44 revealed she could not recall what part of Resident #40's readmission assessment she completed upon the resident's return from the hospital on [DATE]. She vaguely remembered the resident as it was several months ago. She confirmed she worked on 12/17/22 and came to work at 7:00 P.M. She indicated, if the admission packet was signed off by her then, she would have been the one to complete the admission assessment. She would have received report and then would have completed the admission assessment before she started her evening medication pass. She could not recall if the resident had any abnormal findings during her admission assessment and would have to refer to what she documented in the admission assessment. She was informed of what she had documented in her admission assessment pertaining to the resident having difficulty breathing, labored respirations, inspiratory wheezes throughout her bilateral lungs, lethargy, confusion, and having pale, cool and clammy skin. She indicated, if that was her assessment, she would have questioned why the hospital sent her back that way. She remembered vaguely the resident did not respond well the following morning and that was when she was sent back out to the hospital or the Director of Nursing (DON) was called. She denied she called the doctor and reviewed the resident's admission orders with him as was documented on the admission packet as having occurred on 12/17/22 at 8:00 P.M. She was not sure if anyone had called the physician to notify him of the resident's adverse condition upon her return to the facility. She denied she had any contact with the physician, after she completed the resident's admission assessment. She could not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 6 of 10 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 04/27/2023 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 Level of Harm - Minimal harm or potential for actual harm recall anything that went on with the resident through the night. She stated, if she would have assessed those changes in her condition upon her admission assessment, she would have followed up and monitored the resident's respiratory condition through the night. She could not recall what, if any, medications the resident would have received the evening she returned or through the night. She could not recall what medications were available. Residents Affected - Few On 04/24/23 at 9:15 A.M., an interview with Physician #52 revealed Resident #40's name rang a bell, but he did not recall much about her or anything that may have taken place four months ago. He was provided some information on the resident to help refresh his memory, such as why she was sent out to the hospital on [DATE] and her diagnoses when she returned to the facility on [DATE]. He could not recall the facility contacting him about the resident's adverse condition that was noted with her admission assessment the evening of 12/17/22. He stated he had so many nursing homes and took care of a lot of residents that he was not able to recall any specifics that far back. He was then asked if he would have wanted to be notified of the resident's adverse condition upon her return to the facility as was documented in her admission assessment. He stated, typically yes he should have been contacted, if a resident was struggling and having any distress upon their re-admission to the facility. On 04/24/23 at 9:35 A.M., an interview with the DON confirmed Resident #40's admission assessment did show that she had signs of respiratory distress (difficulty breathing, labored respirations, inspiratory wheezes throughout her lungs bilaterally) upon her return from the hospital. She acknowledged the documentation in the resident's medical record did not provide documented evidence the physician was made aware of the resident's adverse condition upon her return to the facility. She indicated the admission assessment did indicate that the physician was contacted on 12/17/22 at 8:00 P.M. to verify the admission orders and she would have assumed that meant the nurse also reviewed any abnormal findings she had identified as part of the assessment. She acknowledged the nurse that was present at the time the physician notification was indicated to have been made denied she spoke with the physician on that evening regarding anything to do with the resident's readmission orders or her condition upon her return. She also acknowledged the physician did not recall anyone notifying him of that and based on the symptoms documented in the assessment they should have. She was then asked about the resident's MAR's not showing she received her scheduled medications the night of 12/17/22 (after returning from the hospital). She stated they determined that it was a glitch in their computer software system. RN #10 had marked the resident was out to the hospital on [DATE] when she was supposed to give the resident her earlier medications. The system coded the resident out to the hospital for all the administrations that were due on 12/17/22. She had educated the nurses about not doing that and only marking something as not being administered at the time it was scheduled as opposed for marking it for the entire day. She acknowledged (with the symptoms the resident was having upon her return to the facility) the physician indicated the resident may have possibly benefited from the administration of her Formoterol Fumarate that was scheduled for the evening of 12/17/22. She was not sure if those medications were still in the facility when the resident returned or if they had been sent back to the pharmacy. On 04/24/23 at 12:47 P.M., a phone interview with RN #10 revealed she was vaguely familiar with Resident #40. She was not normally on the side of the building where the resident resided on when there. She did not recall working on 12/17/22, when the resident was readmitted to the facility from the hospital. She was not sure what time the resident returned to the facility or what involvement, if any, she had with the admission process. She indicated the vital signs that were obtained at 6:05 P.M. would have been done by the aides at the time the resident arrived at the facility. She was asked if she knew what the resident's condition was when the resident returned to the facility. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 7 of 10 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 04/27/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated she did not really recall. She just remembered her not doing well. She was not sure of anything other than what she may have documented in her charting. She stated if the resident was found unresponsive the morning of 12/18/22, it would have been an emergent event and they would have sent her out immediately. On 04/26/23 at 3:05 P.M., a follow up interview with Physician #52 was conducted to gather more information regarding the resident's condition upon her return to the facility on [DATE]. He was asked what he would have done if the facility's nurse did contact him regarding the resident's adverse condition upon her return from the hospital to include difficulty breathing, labored respirations, inspiratory wheezes throughout bilateral lungs, and lethargy. He replied he probably would have had her go back out to the hospital, if the resident wanted to, or, if not, then to treat her in the facility. He was asked what treatment he could have ordered for the resident and he indicated a breathing treatment such as Albuterol, which was more of a rescue medication as opposed to the Formoteral Fumarate, which was more of a maintenance medication. He was then asked if he would have expected the nurse to notify him if the Formoteral Fumarate was not available to be administered at bedtime as ordered. He stated he gets notified all the time when a scheduled medication was not available from the pharmacy. What could they do other than to wait for the medication to be delivered. He was then asked if the resident's outcome would have been any different if the nurse had contacted him about the resident's condition at the time of her readmission and if he would have sent her back to the hospital. He stated it could have but that was all speculative. She could have had the same outcome even if she had been sent back to the hospital. He felt the bigger issue was the hospital sending the resident back to the facility in that condition. A review of the facility's Change in Condition/ Notification policy (dated July 2016) revealed it was the policy of the facility to comply with the regulations regarding notification of changes in condition. The facility would immediately or at least within 24 hours inform the resident, consult with the resident's physician, and if known, notify the resident's interested family member when there was a significant change in the resident's physical, mental, or psychosocial status (i.e. deterioration in health in either life threatening conditions or clinical complications), a need to alter treatment significantly (i.e. commence a new form of treatment), or a decision to transfer the resident from the facility. This deficiency represents non-compliance investigated under Master Complaint Number OH00141418 and Complaint Number OH00141416. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 8 of 10 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 04/27/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure resident medical records were complete and accurate to include documentation of falls when they occurred. This affected two (#37 and #40) of eight resident records reviewed in six areas (falls, infections, dehydration, rehabilitation services, nutrition, and psychoactive medications) of the complaint. Findings include: 1. A review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia with agitation, adult inset diabetes mellitus, heart failure, difficulty in walking, muscle weakness, restlessness and agitation, and need for assistance with personal care. A review of Resident #37's fall investigations in the past three months revealed she sustained four falls while in the facility over that three month period. Falls occurred on 02/18/23, 02/20/23 at 1:30 A.M., 02/20/23 at 3:00 A.M., and 02/20/23 at an unspecified time. The incident report/ fall investigation indicated they were not part of the resident's medical record and were privileged and confidential. A review of Resident #37's nurses' progress notes revealed there were no documentation in the progress notes of the resident having sustained any falls between 02/18/23 and 02/20/23. Findings were verified by the Director of Nursing (DON). On 04/24/23 at 4:40 P.M., an interview with the DON revealed they had identified issues with falls not being documented in the electronic health record (EHR) when Resident #40's falls not being documented in the EHR was brought to her attention. She stated they had narrowed the issue down to a couple of nurses and would be providing education to them on the need to document falls in the progress notes when they occurred. 2. A review of Resident #40's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with agitation, chronic obstructive pulmonary disease, muscle weakness, difficulty walking, lack of coordination, impulse disorder, muscle wasting and atrophy, psychotic disorder with delusions, hypertension, and osteoporosis. A review of Resident #40's fall investigations revealed the resident sustained four falls while she was in the facility between 11/03/22 and 12/18/22. Falls were indicated to have occurred on 11/03/22, 11/29/22, 12/07/22, and 12/11/22. A review of Resident #40's progress notes revealed there was no documentation in the progress notes of the resident having sustained a fall on 11/03/22 or 12/07/22. Findings were verified by the DON. On 04/24/23 at 3:25 P.M., an interview with the DON confirmed Resident #40 had falls occurring on 11/03/22 and 12/07/22 that were identified on an incident reports/ fall investigations that were not documented in the nurses' progress notes. She stated the only place she found documentation indicating falls had occurred on those dates were in the care plan and in the fall risk assessments. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 9 of 10 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 04/27/2023 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 0842 confirmed falls should be documented in the EHR under the progress notes when they occurred. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Master Complaint Number OH00141418 and Complaint Number OH00141416. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 10 of 10