Inspection·August 23, 2023

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/22/23 at 11:20 A.M. with RN #100 verified she did use one washcloth with soap and water to clean the entire wound, used one washcloth to rinse the wound, and used a towel to dry to wound. She also verified the facility did have wound care products to use to clean pressure ulcer wounds. Interview on 08/22/23 at 11:30 A.M. with the DON verified physician orders for wound care are to be followed. Interview on 08/22/23 at 11:50 A.M. with RN #100 verified Resident #37 did not have a dressing on his buttock/coccyx pressure ulcer when she removed his undergarment, and she did not apply a foam dressing as ordered. She reported she did go back and apply a foam dressing after it was brought to her attention by the director of nursing. Review of facility policy titled, Dressing Change - Clean, undated, revealed the purpose of the policy was to provide guidelines for the proper application of a dry, clean dressing. Further review revealed the nurse was to verify the physician's order for the appropriate treatment; open the dry clean dressing; using a clean technique open the other products used to clean the wound; pour the prescribed cleansing solution over the dry, clean gauze; cleanse the wound using clean gauze with each cleansing stroke, clean from the least contaminated areas to the most contaminated areas which is usually from the center outward; use a dry gauze to pat the wound dry; and apply the ordered treatment and dressing. This deficiency represents non-compliance investigated under Complaint Number OH00145356. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 2 of 15 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 08/23/2023 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 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. Based on observation, interview, resident record review and facility policy review, the facility failed to ensure incontinence care was provided timely. This affected one resident (#27) of three residents reviewed for incontinence care. The facility census was 43. Findings included: Review of Resident #27's medical record revealed an initial admission dated of 07/05/18 and a readmission date of 12/01/20 with diagnoses including multiple sclerosis, type two diabetes, morbid obesity, and generalized muscle weakness. Review of Resident #27's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/04/23, revealed she was cognitively intact. The assessment indicated she needed extensive assistance of two plus persons for physical assistance with toilet use and she was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #27's plan of care, dated 07/09/18, revealed she had an alteration in elimination, was frequently incontinent of bladder and occasionally incontinent of bowel. Added on 07/29/19 was that she was always incontinent of bladder. Interventions included provide incontinent care as needed. Interview on 08/21/23 at 9:38 A.M. with Resident #27 revealed she was incontinent at times and the staff are not always timely with incontinence care. She reported sometimes she has to wait over 30 minutes for incontinence care. Interview on 08/21/23 at 9:45 A.M. with Resident #27 revealed the facility did not provide prompt incontinent care. She reported she informed State Tested Nursing Assistant (STNA) #117 at 8:23 A.M. she needed assistance to her chair. She reported she always received incontinence care prior to getting in her chair. Resident #27 reported she had yet to receive the incontinence care and was soiled with bowel movement. Observation at the time of a stool like odor from Resident #27. Interview on 08/21/23 at 10:10 A.M with (STNA) #117 revealed Resident #27 had requested at around 8:23 A.M. to be assisted to her chair. STNA #117 reported incontinence care was not yet provided for Resident #27 and that Resident #27 received her incontinence care just prior to being assisted to her chair. STNA #117 verified based on this information, Resident #27 had been waiting on incontinence care for one hour and 47 minutes. STNA #117 verified that was too long to wait for incontinence care. Interview on 08/21/23 at 12:28 P.M. with the director of nursing (DON) verified incontinence care should be completed in a timely manner. Review of the facility policy titled, Incontinence Care, undated, revealed the purpose of incontinence care is to maintain skin integrity, prevent skin breakdown, control odor and provide comfort and self-esteem for the resident. This protocol is to be utilized on residents who are incontinent of bowel and/or bladder. This deficiency represents non-compliance investigated under Complaint Number OH00145356. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 3 of 15 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 08/23/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, resident record review and facility policy review, the facility failed to ensure they maintained a medication error rate of less than 5%. This affected three residents (#7, #20, and #29) of five residents observed for medication observation and resulted in a medication error rate of 13.95%. There was total of 43 opportunities for error during the medication administration observation and the facility had a total of six medication errors resulting in a medication error rate of 13.95%. The facility census was 43. Residents Affected - Few Findings included: 1. Review of Resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses including unspecified fracture of the unspecified lumbar vertebra, malignant neoplasm of the unspecified site, dementia in other disease classified elsewhere, Alzheimer's disease, anxiety disorder, and essential hypertension. Review of Resident #20's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/09/23, revealed she was severely cognitively impaired. Review of Resident #20's physician order, dated 07/13/23, identified she was to receive Ativan one milligram (mg) by mouth three times a day for anxiety and give one mg by mouth every three hours as needed for anxiety/restlessness; physician order, dated 07/03/23, identified she was to receive Tramadol oral tablet 50 mg by mouth three times a day for pain; and physician order, dated 07/03/23, identified she was to receive Seroquel 50 mg by mouth three times a day for behaviors. Review of Resident #20's physician orders revealed no order for her medications to be crushed. Observation on 08/21/23 at 12:07 P.M. of Registered Nurse (RN) #100 placing an Ativan one mg tablet, a Tramadol 50 mg tablet, and a Seroquel 50 mg tablet in a small plastic bag for medication crushing. RN #100 then crushed the three medications, mixed them with pudding and administered them to Resident #20. Interview on 08/21/23 at 1:56 P.M. with RN #100 verified Resident #20 did not have an order for her medications to be crushed and for medications to be administered in a crushed form there must be an order. There were three opportunities for medication error and three medication errors did occur due to there was no order to crush Resident #20's medications. Review of the facility policy titled, Medication Administration General Guidelines, dated 09/10, revealed if it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from prescriber. Further review revealed the need for crushing medications is indicated on the resident's order and the MAR so that all personnel administering medications are aware of this need the consultant pharmacist can advise on safety and alternatives, if appropriate, during Medication Regimen Reviews. 2. Review of Resident #29's medical record revealed she was initially admitted to the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 4 of 15 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 08/23/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE] and readmitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction (stroke), type two diabetes, vascular dementia, iron deficiency, and essential hypertension. Review of Resident #29's annual Minimum Data Set (MDS) 3.0 assessment, dated 05/28/23, revealed she was slightly cognitively impaired Review of Resident #29's physician order, dated 06/20/23, identified she was to receive ferrous gluconate 324 mg one tablet by mouth two times a day for a supplement; physician order, dated 08/26/21, identified she was to receive magnesium oxide 400 mg by mouth two times a day for a supplement; physician order, dated 06/20/23, identified she was to receive Florastor capsule 250 mg by mouth two times a day for a supplement; physician order, dated 06/20/23, identified she was to receive Metformin 1000 mg one tablet by mouth two times a day for diabetes; physician order, dated 06/20/23, identified she was to receive metoprolol tartrate one half of a 25 mg tablet twice daily; and physician order dated 06/20/23, identified she was receive artificial tears, instill one drop in both eyes two times a day for dry eyes. Review of Resident #29's physician order, dated 08/18/21, identified she was to receive Vascepa Capsule one gram and give two capsules by mouth in the morning for cholesterol and give two capsules by mouth at bedtime for cholesterol. Observation on 08/21/23 at 3:00 P.M. of RN #89 preparing Resident #29's medications for administration revealed the following medications were placed in a cup for Resident #29: ferrous gluconate 324 mg (one tablet), magnesium oxide 400 mg (one tablet), Metformin 1000 mg (one tablet), metoprolol 25 mg (one half of a tablet), and Vascepa one gram (two tablets). RN #89 verified her pill count was five and one half. RN #89 administered the oral medications to Resident #29 and then proceeded to administer the eye drops. RN #89 did not administer the Florator as ordered and administered Vascepa when it was not due. Review of Resident #29's medication administration record (MAR), dated 08/23, revealed the Florastor capsule 250 mg was marked as administered and there was no documentation of the Vascepa one gram (two tablets) being administered. Interview on 08/21/23 at 4:00 P.M. with RN #89 verified she did not administer the Florastor capsule 250 mg as ordered even though it was marked as administered on the 08/21/23 MAR. RN #89 verified she did administer Vascepa one gram two capsules and she should not have due to it was not due to be administered. There were six opportunities for medication error and two medication errors did occur due to Resident #29 not receiving her Florastor capsule as ordered and receiving two capsules of the Vascepa one gram when it was not due to be administered. 3. Review of Resident #7's medical record revealed she was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including transient cerebral ischemic attack, type two diabetes, chronic kidney disease, hyperparathyroidism and muscle wasting and atrophy. Review of Resident #7's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/04/23, revealed she was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 5 of 15 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 08/23/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #7's physician order, dated 01/20/20, identified she was to receive atenolol 25 mg one tablet by mouth two times a day; physician order, dated 10/21/20 identified she was to receive docusate sodium capsule 100 mg give two capsules by mouth in the evening for constipation; physician order, dated 01/02/20, identified she was to receive Amlodipine 5 mg one tablet by mouth two times a day for hypertension; and physician order, dated 01/02/23, identified she was to receive Atorvastatin calcium tablet 40 mg give one and one half tablets by mouth in the evening for hyperlipidemia. Observation on 08/21/23 at 3:09 P.M. of RN #89 preparing Resident #7's medications for administration revealed the following medications were placed in a cup for Resident #7: Atorvastatin 40 mg (one tablet) and docusate sodium 100 mg (two tablets). RN #89 knocked the medication cup over, the medications came out of the cup and landed on the top of the medication cart. RN 89 discarded the medications. RN #89 then placed the following medications in the medication cup for Resident #7: atenolol 25 mg (one tablet), docusate sodium 100 mg (two tablets) and Amlodipine 5 mg (one tablet). RN #89 verified her pill count was four. RN #89 administered the oral medications to Resident #7. RN #89 did not administer the Atorvastatin as ordered. Review of Resident #7's medication administration record (MAR), dated 08/23, revealed the Atorvastatin 40 mg PO one and one-half tablets was marked as administered. Interview on 08/21/23 at 4:50 P.M. with RN #89 verified she did not administer the Atorvastatin as ordered and did mark it as administered on the MAR. There were four opportunities for medication error and one medication error did occur due to Resident #7 not receiving her Atorvastatin 40 mg one and one-half tablets as ordered. Review of the facility policy titled, Medication Administration General Guidelines, dated 09/10, revealed medications are administered in accordance with written orders of the prescriber. There was total of 43 opportunities for error during the medication administration observation and the facility had a total of six medication errors resulting in a medication error rate of 13.95%. This deficiency represents non-compliance investigated under Master Complaint Number OH00145381. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 6 of 15 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 08/23/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility policy review, the facility failed to ensure liquid medications were stored in a way to prevent contamination. This affected one resident (#4) of five residents observed for medication administration. The facility census was 43. Findings included: Observation on 08/21/23 at 12:14 P.M. as Registered Nurse (RN) #100 prepared medications for Resident #4. RN #100 poured Resident #4's liquid Carafate medication in a plastic medication cup and then sat the cup on the top of the medication cart. She then lowered herself, so she was at eye level with the medication cup to check the amount. RN #100 had poured more than what was ordered for Resident #4 into the medication cup. RN #100 then picked up the medication cup with the Carafate in it and poured some of the liquid medication back into the medication bottle the medication was originally poured from. This action resulted in contamination of the bottle of medication. Interview on 08/21/23 at 12:25 P.M. with RN #100 verified she should not have returned the liquid Carafate she over poured into the medication bottle. RN #100 verified she should have discarded the extra Carafate. Review of the facility policy titled, Storage of Medications, dated 09/10, revealed medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Review of the facility policy titled Medication Administration General Guidelines, dated 09/10, revealed once a medication is removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy. Review of the facility policy titled, Disposal of Medications, Syringes, and Needles: Disposal of Medications, dated 03/09, revealed outdated medications, contaminated or deteriorated medications, and the contents of the containers with no label shall be destroyed. This deficiency is cited as an incidental finding to Master Complaint Number OH00145381. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 7 of 15 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 08/23/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility policy review, the facility failed to ensure food storage and food handling was completed in a sanitary manner, failed to ensure pest control in the kitchen, failed to ensure food service equipment was clean, and failed to maintain documentation of food temperatures prior to serving, dishwasher sanitation requirements being met, and sanitation bucket requirements being met. This had the potential to affect 42 of 43 residents receiving food from the kitchen. Facility documentation revealed Resident #42 did not receive any food by mouth. Findings included 1. Observation on 08/21/23 at 7:45 A.M. of the right reach in refrigerator revealed approximately six ounces of possibly bologna which was opened and not labeled or dated, approximately eight ounces of roast beef which was opened and not dated, and a single hot dog which was in an unsealed bag and was also not dated. Observation on 08/21/23 at 7:47 A.M. of the left reach in refrigerator revealed one half of a large bag of lettuce which was open and not dated. The lettuce in the bottom of the bag was starting to become watery. Interview on 08/21/23 at 7:48 A.M. with Dietary Manager #113 verified the above food items were not properly stored. She verified they should have been labeled with product name and open date and properly sealed in a storage container. The Dietary Manger #113 verified without an open date, one would not know when to discard the item. Review of the facility policy titled, Date Marking, dated 09/2016, revealed any ready-to-eat, potentially hazardous foods prepared and held in refrigeration for over 24 hours, shall be date marked utilizing an established procedure to ensure food safety. Further review revealed foods that are considered held under refrigeration or cumulatively more than 24 hours before service shall be dated marked. 2. Observation on 08/21/23 at 11:36 A.M. of Dietary [NAME] #111 pulling his face mask down and touching his nose with his gloved left hand. Dietary [NAME] #111 did not remove his glove until Dietary Manager #113 directed him to do so and then he did not wash his hands, but simply doffed (removed) the glove on the left hand and donned (put on) a new glove on the left hand. Observation on 08/21/23 at 11:48 A.M. of Dietary [NAME] #111 using his left gloved hand to push salad into the one cup measuring cup he was using to measure the salad. He then touched lids on the steam table, a dishwasher container of bowls, and knives used to cut pizza with the left gloved hand. Dietary [NAME] #111 returned to the salad bowl and used his left gloved hand to push salad into the one cup measure cup he was using to measure the salad. Observation at this same time also revealed he was removing slices of pizza from the steam table with his gloved hands and placing them on the residents' plates after he touched lids on the steam table, a dishwasher container of bowls, and knives used to cut pizza. Interview on 08/21/23 at 11:52 A.M. with Dietary Manager #113 verified Dietary [NAME] #111 should not be touching surfaces with gloved hands and then touching residents' food with those gloved hands and he should have also washed his hands when he removed his gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 8 of 15 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 08/23/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 08/21/23 at 11:54 A.M. with Dietary [NAME] #111 verified he should not have been touching the salad and pizza with gloved hands after touching other surfaces with the gloved hands. He verified he should have used a tong to retrieve the pizza from the steam table and used the measuring cup only to retrieve the salad from the salad bowl. 3. Observation on 08/21/23 at 7:50 A.M. of multiple flies flying in the kitchen and landing on various surfaces (counter tops, handles of kitchen utensils, and staff). There was an observation of a new fly swatter in the dry storage area which had not been open. An interview at the time with Dietary Manager #113 verified the facility had a fly problem for a couple of weeks. Observation on 08/21/23 at 11:55 A.M. of peaches plated and prepared to be placed on residents' trays for lunch on a tray in the kitchen. The peaches were not covered, and a fly landed on a peach. Dietary Aide #110 verified a fly landed on the food prepared for residents. The Dietary Aide #110 did not pick up the peaches to discard them until Dietary Manager #113 directed her to do so. Dietary Aide #110 then covered the peaches after the Dietary Manager #113 directed her to do so. 4. Observation on 08/21/23 at 7:45 A.M. of the ice machine sitting in the residents' dining area revealed it was dirty on the outside and the inside. The outside was covered in a white substance and there were black spots on the ice curtain. Interview on 08/21/23 at 10:33 A.M. with the Dietary Manager #113 verified the ice machine had a black substance on the ice curtain and the outside was dirty also. She verified ice had been used from the machine on 08/21/23 and that it was the responsibility of the maintenance department to clean the inside of the ice machine. She verified the dietary staff were to clean the outside of the ice machine. Interview on 08/22/23 at 10:22 A.M. with the Maintenance Director (MD) #94 revealed he did a chemical clean on the ice machine one to two times a month because of the calcium buildup. He reported he removed the ice, ran the chemicals through it, and wiped the basin out. He denied cleaning the curtain of the ice machine when he did the chemical clean. Observation on 08/22/23 at 10:26 A.M. of the facility ice machine with MD #94 revealed the curtain had a black substance and there was a black substance in the ice. MD #94 verified the dirty curtain and the dirt in the ice. MD #94 obtained a scoop, retrieved the black substance from the ice and discarded it. The ice machine was not emptied and cleaned at the time. Review of the facility documentation titled, Work History Report, revealed on 09/30/22, 12031/22 0331/23 and 06/30/23 the ice machine's filters were checked, coils were cleaned, the interior was sanitized, and the machine was delimed as necessary. Review of the facility policy titled, Ice Machine Cleaning Policy, dated 02/18, the purpose of the policy was to ensure that the production, serving, and holding of ice is in compliance with the Ohio Food Code and

F812 Food Procurement, Store/Prepare/Serve - Sanitary and F880 Infection Control. Further review revealed ice machine shall be sanitized monthly by maintenance personnel, documentation of cleaning will be kept for one year, and the ice machine was to be free of rust and mildew at all times. 5. Review of food temperature logs for the month of June 2023 revealed the following items had no documentation to confirm they were temperature checked prior to serving: on 06/06/23 lunch items of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 9 of 15 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 08/23/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many baked beans, corn and oranges and dinner items of sloppy joe and tater tots; on 06/08/23 lunch items of tuna salad sandwich, potato salad, beets and pears and dinner items of glazed ham, sweet potatoes and corn; on 06/19/23 lunch items of barbecue chicken, baked beans, corn, and oranges and dinner items of sloppy joe, tater tots, and mixed vegetables; on 06/23/23 lunch items of fish nuggets, haluski, broccoli, and fruit and dinner items of meatloaf, fired potatoes, squash and cheese biscuit; on 06/25/23 lunch items of General Tso's chicken, rice, and oriental vegetables and dinner items of glazed ham, cheesy potatoes, peas, biscuit, and apples; on 06/28/23 lunch item of tossed salad and dinner items of Swedish meatballs, rice, corn, and cherry crisp; and on 06/30/23 lunch items of vegetable soup and barbecue port sandwich. Further review revealed each one of these food temperature logs did not have documentation to support milk or any other drink was temperature checked. Review of the food temperature logs for the month of July 2023 revealed the following items had no documentation to confirm they were temperature checked prior to serving: on 07/05/23 lunch items of spaghetti and garden salad and dinner item of French fries. Further review revealed each one of these food temperature logs did not have documentation to support milk or any other drink was temperature checked. Review of the food temperature logs for the month of August 2023 revealed the following items had no documentation to confirm they were temperature checked prior to serving: on 08/01/23 lunch item of fruit; on 08/02/23 breakfast items of eggs, oats, and cream of wheat, lunch item of hot dogs, and dinner items of sausage and eggs; on 08/03/23 breakfast items of sausage, pancakes, oats, and cream of wheat, lunch item of mashed potatoes, and dinner items of salad and green beams; on 08/04/23 breakfast items of oats, cream of wheat and lunch items of fruit and hot dogs; on 08/05/23 breakfast items of sausage, bacon, fried eggs, pancakes, oats and cream of wheat and dinner item of oranges; on 08/06/23 breakfast items of omelets, fried eggs, sausage and bacon and lunch items of egg salad sandwich, and three bean salad; on 08/07/23 breakfast items of fried eggs, sausage, and bacon and lunch items of pears; on 08/08/23 breakfast items of ham slices and cream of wheat and dinner item of gravy; on 08/09/23 breakfast items of oats, cream of wheat and eggs, lunch items of fried chicken, mashed potatoes, peas, and gravy, and dinner items of cheese pasts, salad and fruit; on 08/10/23 breakfast items of oatmeal, cream of wheat, and French toast, lunch item of marinated tomato and onion salad, and dinner items of noodles and fruit; on 08/11/23 breakfast items of French toast, oatmeal, and cream of wheat and lunch item of fruit; on 08/12/23 breakfast item of bacon and lunch items of tuna steak, sweet potatoes and peas; on 08/13/23 breakfast items of bacon, oatmeal, cream of wheat; on 08/14/23 breakfast items of eggs, oatmeal and cream of wheat; on 08/15/23 breakfast items of oatmeal and cream of wheat, lunch items of cucumbers and tomatoes; on 08/16/23 breakfast items of oatmeal and cream of wheat; on 08/17/23 breakfast items of oatmeal, cream of wheat, eggs and bacon and lunch item of chocolate mousse; on 08/18/23 breakfast items of oatmeal and cream of wheat and lunch items of three bean salad, and pineapple dream; on 08/19/23 breakfast items of oatmeal and cream of wheat, lunch item of egg salad and dinner item of gravy; and on 08/20/23 breakfast items of oatmeal, and cream of wheat, lunch item of peach crisp, and dinner item of fruit. Further review revealed each one of these food temperature logs did not have documentation to support milk or any other drink was temperature checked. Interview on 08/21/23 at 7:55 A.M. with Dietary Manager #113 verified if food temperatures are not logged, there is no way to know the temperatures were checked. She also verified that if the food temperatures are not checked, there is no way to know if the food was cooked to a safe temperature or cold items were held at a safe temperature. Review of the facility policy titled, Food Temperatures, undated, revealed the temperatures of all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 10 of 15 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 08/23/2023 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 0812 food items will be taken and properly recorded prior to service of each meal. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, General HAACP Guidelines for Food Safety, undated, revealed check to be sure that staff takes food temperatures correctly and records temperatures. Residents Affected - Many 6. Review of the High Temperature Dish Machine Log dated for 04/2023 revealed no documentation to support the dishwasher was not temperature checked to verify sanitation of washed items at dinner time on 04/21/23, 04/25/23, 04/28/23, 04/29/23 or 04/30/23. Review of the High Temperature Dish Machine Log dated for 05/23 revealed no documentation to support the dishwasher was not temperature checked to verify sanitation of washed items at breakfast on 05/26/23 and 05/27/23, at lunch on 05/27/23, 05/28/23, 05/29/23, 05/30/23, or 05/31/23, and at dinner on 05/03/23, 05/04/23, 05/07/23, 05/08/23, 05/09/23, 05/13/23, 05/14/23, 05/17/23, 05/18/23, 05/20/23, 05/22/23, 05/27/23, 05/28/23, 05/29/23, 05/30/23, and 05/31/23. Review of the High Temperature Dish Machine Log dated for 06/23 revealed no documentation to support the dishwasher was not temperature checked to verify sanitation of washed items at dinner on 06/01/23, 06/02/3, 06/03/23, 06/04/23, 06/05/23, 06/06/23, 06/07/23, 06/08/23, 06/09/23, 06/10/23, 06/11/23, 06/12/23, 06/13/23, 06/14/23, 06/15/23, 06/17/23, 06/18/23, 06/19/23, 06/20/23, 06/21/23, 06/22/23, 06/23/23, 06/24/23, 06/25/23, 06/26/23, 06/27/23, 06/28/23, and 06/29/23. Review of the High Temperature Dish Machine Log dated for 08/23 revealed no documentation to support the dishwasher was not temperature checked to verify sanitation of washed items at breakfast on 08/01/23, lunch on 08/01/23, and dinner on 08/01/23 and 08/02/23. Interview on 08/21/23 at 8:20 A.M. with the Dietary Manager #113 verified there was documentation missing to confirm the high temperature dishwasher was monitored to confirm it reached a sanitizing temperature. She verified the dishwasher temperature should be monitored regularly to verify sanitation is occurring. Review of the facility policy titled, Dish Machine Temperatures/Records/Sanitizer, dated 01/2019, revealed dish machine temperatures and/or sanitizer strengths (as indicated) shall be monitored prior to each meal and recorded to prevent foodborne illness by ensuring all food contact surfaces are properly cleaned and sanitized. Further review revealed the wash and final rinse temperatures of the dish machine shall be monitored and recorded prior to each meal periods' ware washing by the dietary staff and additionally needed per professional judgment. The Dietary Manager shall be responsible for assuring that the record of dish machine temperatures is maintained at all times. Review of the facility policy titled, General HAACP Guidelines for Food Safety, undated, revealed be sure the wash and rinse temperatures are appropriate for the dish machine and document temperatures regularly on a temperature log. 7. Review of the Bucket PPM Tracking Log dated for 04/23 revealed no documentation to support the parts per million (PPM) chemical sanitation concentration was monitored to verify the solution met the requirement for sanitation on 04/29/23 at 5:00 A.M., 9:00 A.M., 12:00 P.M., 3:00 P.M. or 6:00 P.M. Review of the Bucket PPM Tracking Log dated for 05/23 revealed no documentation to support the parts per million (PPM) chemical sanitation concentration was monitored to verify the solution met the requirement for sanitation on 05/09/23 at 12:00 P.M., 3:00 P.M. or 6:00 P.M.; on 05/12/23 at 12:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 11 of 15 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 08/23/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm P.M.; on 05/13/23 at 3:00 P.M. or 6:00 P.M.; on 05/14/23 at 3:00 P.M. or 6:00 P.M.; on 05/17/23 at 12:00 P.M., 3:00 P.M., or 6:00 P.M.; 05/18/23 at 3:00 P.M. or 6:00 P.M.; on 05/20/23 at 12:00 P.M., 3:00 P.M. or 6:00 P.M.; on 05/22/23 at 12:00 P.M., 3:00 P.M. or 6:00 P.M.; on 05/26/22 at 3:00 P.M. or 6:00 P.M.; on 05/26722 at 3:00 P.M. or 6:00 P.M.; on 05/28/22 at 3:00 P.M. or 6:00 P.M.; on 05/29/22 at 3:00 P.M. or 6:00 P.M.; on 05/23022 at 3:00 P.M. or 6:00 P.M.; or on 05/26/22 at 3:00 P.M. or 6:00 P.M. Residents Affected - Many Review of the Bucket PPM Tracking Log dated for 06/23 revealed no documentation to support the parts per million (PPM) chemical sanitation concentration was monitored to verify the solution met the requirement for sanitation on 06/12/23 at 3:00 P.M. and 6:00 P.M. Review of the Bucket PPM Tracking Log dated for 08/23 revealed no documentation to support the parts per million (PPM) chemical sanitation concentration was monitored to verify the solution met the requirement for sanitation on 08/01/23 at 12:00 P.M., 3:00 P.M. and 6:00 P.M. Interview on 08/21/23 at 8:20 A.M. with the Dietary Manager #113 verified there was documentation missing to confirm the sanitation bucket concentration met the requirement for sanitizing. She verified the sanitation bucket sanitation concentration should be monitored regularly to verify sanitation is occurring. Review of the facility policy titled, Sanitation Monitoring Policy, dated 08/2016, revealed the purpose of the policy was to ensure that the proper amount of sanitation is being utilized for the sanitation buckets and three compartment sink. Further review revealed buckets would be filled at the beginning of the A.M. shift. The person filling will check the PPM to ensure that it meets 400. If the bucket did not meet 400 PPM, it was not to be utilized. This deficiency represents non-compliance investigated under Complaint Number OH00145356. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 12 of 15 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 08/23/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility policy review, the facility failed to ensure staff wore appropriate personal protective equipment when the facility was in COVID-19 outbreak, performed hand hygiene, did not touch items with soiled gloves, and cleaned and disinfected a glucometer used by multiple residents. This affected Residents #7, #27, and #29 and had the potential to affect all 43 residents. Residents Affected - Many Findings included: 1. Observation on 08/21/23 at 7:30 A.M., upon entrance into the facility, of a sign on the exterior main entrance door which informed anyone entering the building the facility was in a COVID-19 outbreak. Observation on 08/21/23 at 7:31 A.M. of Licensed Practical Nurse (LPN) #95 and Registered Nurse (RN) # 100 sitting at the east nurses' station not wearing any masks. An interview at the time revealed the facility was in COVID-19 outbreak and per their facility policy they should be wearing N-95 masks. Neither LPN #95 of RN #100 were wearing eye protection. Observation on 08/21/23 at 7:32 A.M. of Housekeeping Aide #101 delivering meals to residents sitting in the dining area with no mask. Observation during the same time of Dietary Manager (DM) #113 working in the kitchen with no mask. An interview with DM #113 revealed she did not need to wear a mask because she was not providing care or services at that time for residents. Neither Housekeeping Aide #101 nor DM #113 were wearing eye protection. Housekeeping AIDE #101 placed a N-95 mask on after seeing this surveyor. Observation on 08/21/23 at 7:35 A.M. of Social Services Director #97 with a N-95 mask on with both the top strap and the bottom strap behind her neck. The N-95 mask did not have a seal on the sides and she was working with a resident at the time. The resident did not have a mask on. An interview at the time with SSD #97 verified she was not wearing her N-95 mask correctly and the top strap should go up over the crown of her head. Observation on 08/21/23 at 7:36 A.M. of State Tested Nursing Assistant (STNA) #87 with a N-95 mask on with both the top strap and the bottom strap behind her neck. The N-95 mask did not have a seal on the sides and she was working with a resident at the time. The resident did not have a mask on. An interview at the time with STNA #87 verified she was not wearing her N-95 mask correctly and the top strap should go up over the crown of her head. Observation on 08/21/23 at 7:40 A.M. of Laundry Assistant #86 walking in the hallway on the west side of the building near the laundry room. She was wearing a N-95 mask with both the top strap and the bottom strap behind her neck. The N-95 mask did not have a seal on the sides. An interview at the time revealed Laundry Assistant #86 did not know the top strap needed to go over the crown of the head. She reported she had never been educated on how to wear the mask. Laundry Assistant #86 was not wearing eye protection. Observation on 08/21/23 at 7:42 A.M. of RN #89 near her medication cart on the west side of the building. She was wearing a N-95 mask with both the top strap and the bottom strap behind her neck. An interview at the time revealed RN #89 did not know the top strap needed to go over the crown of the head. She reported she had never been educated on how to wear the mask. RN #89 was not wearing eye (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 13 of 15 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 08/23/2023 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 0880 protection. Level of Harm - Minimal harm or potential for actual harm Interview on 08/21/23 at 8:00 A.M. with the DON revealed the facility was in continued COVID-19 outbreak due to staff testing positive. The DON revealed there were currently no residents who were positive. She reported the staff in the facility should be wearing N-95 masks and eye protection per facility policy. Residents Affected - Many Review of the facility documentation titled, LTC Respiratory Surveillance Line List, revealed Resident #19 was the first resident or staff to present with symptoms and test positive for COVID-19 on 07/17/23. Since then, two additional residents and four staff had tested positive for COVID-19. Review of the facility policy titled, Coronavirus Prevention and Response, undated, revealed source control options for healthcare providers include a NIOSH-approved particulate respirator with N95 filters or higher, a respirator approved under standards used in other countries that are similar to NIOSH- approved N95 filtering facepiece respirators, a barrier face covering the meets ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Plus mask, and a well-fitting facemask. 2. Observation on 08/21/23 at 3:00 P.M. of Registered Nurse (RN) #89 preparing and administering oral medications and eye drops for Resident #29. RN #89 did not perform hand hygiene prior to preparing medications. RN #89 provided Resident #29, who was sitting in the dining area, her oral medications then walked over to get gloves off of medication cart near the east nurses' station. She did not perform hand hygiene prior to donning (putting on) the gloves. She then proceeded to administer one drop of artificial tears in each eye of Resident #29. RN #89 removed her gloves and did not wash her hands. Interview on 08/21/23 at 3:57 P.M. with RN #89 verified she did not perform hand hygiene prior to preparing Resident #29's medications, donning the gloves to administer eye drops, or after doffing (removing) the gloves. She verified she should have performed hand hygiene prior to preparing the medications, donning the gloves for eye drop administration, and doffing the gloves. Review of the facility policy titled, Medication Administration General Guidelines, dated 09/10, revealed hands are washed with soap and water before and after administration of topical, ophthalmic (eye), otic, parenteral, enteral, rectal, and vaginal medications, and with any resident contact. 3. Observation on 08/21/23 at 10:15 A.M. of incontinence care for Resident #27 being provided by STNA #98 and STNA #117 revealed the STNAs gathered supplies, performed hand hygiene, and donned (put on) gloves. The STNAs removed the top linen revealing Resident #27 had stool coming out of her depends anteriorly onto her left leg. STNA #98 repositioned Resident #27 and washed, rinsed, and dried her back. STNA #98 then assisted Resident #27 supine (on her back) and unhooked her depends. He then rolled her depends under toward her. While doing this process, his gloved right hand went into the stool which was coming out of the depends onto Resident #27's left leg. STNA #98 walked to Resident #27's wardrobe, opened it using the same gloved hand which had touched stool, obtained body wash with his left gloved hand, squirted the body wash onto a washcloth, and then closed the wardrobe with his left hand. STNA #98 cleaned, rinsed, and dried Resident #27's peri area front to back. STNAs #98 and #117 then rolled Resident #27 onto her right side. STNA #98 walked into Resident #27's bathroom, which she shared with the resident next door, and got additional wash cloths wet. STNA #98 walked to Resident #27's wardrobe, opened it using the same gloved hand which had touched stool, obtained body wash with his left gloved hand, squirted the body wash onto a washcloth and then closed the wardrobe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 14 of 15 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 08/23/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many with his left hand. STNA #98 hand the soapy washcloth to STNA #117 and she clean Resident #27 posterior area of the stool. During the entire process STNA #98 did not change his gloves or wash his hands after touching the stool early in the process and he proceeded to touch Resident #27's wardrobe and bathroom doorknob with the soiled gloves. Interview on 08/21/23 at 10:27 P.M. with STNA #98 verified his gloved hands did come in contact with Resident #27's stool at the beginning of the incontinence care and he touched several items with the soiled gloved hand. He verified he should have removed his gloves and performed hand hygiene several times while providing incontinence care. Interview on 08/21/23 at 12:28 P.M. with the DON verified items should not be touched with soiled gloves to prevent the potential for spread of infection. Review of the facility policy titled, Hand Washing, dated 03/20, revealed hands should be washed at a minimum before and after each resident contact and after handling any contaminated items (linens, soiled diapers, garbage, etc.) 4. Observation on 08/21/23 at 3:09 P.M. of RN #89 preparing to obtain a finger stick blood sugar (FSBS) and preparing medications for Resident #7. RN #89 gathered her supplies: the glucometer, a lancet, a bottle of monitor strips, and alcohol swabs. RN #89 then donned (put on) gloves and entered Resident #7's room with her supplies. RN #89 proceeded to lie the glucometer on Resident #7's over bed table without a barrier between the glucometer and the table. The FSBS was obtained and then RN #89 left the room, discarded the lancet and used test strip in a sharps container, and laid the glucometer on the top of the medication cart. RN #89 then placed the glucometer in in the top right drawer. During the observation, at no time did RN #89 sanitize her hands or was the glucometer used by multiple residents cleaned. Interview on 08/21/23 at 3:20 P.M. with RN #89 verified she did not sanitize her hands prior to preparing medications or donning gloves to obtain a FSBS for Resident #7. She also verified she laid the shared glucometer on Resident #7's over bed table without a barrier, after completing the FSBS she returned to the medication cart and laid the glucometer on top of the medication cart, and then put the glucometer in the top right drawer. She verified she did not clean the glucometer at any time. Review of the facility policy titled, Cleaning and Disinfecting of Equipment, undated, revealed the licensed nurse will clean and/or disinfect the equipment to include scissors, thermometers, and blood glucose meter after each use for the individual patient. This deficiency is cited as an incidental finding Master Complaint OH00145381. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 15 of 15