Inspection·November 14, 2023

F 0558 This deficiency represents non-compliance investigated under Master Complaint Number OH00147907. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 2 of 14 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 11/14/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, resident council minute review, housekeeping checklist review, and facility policy review, the facility failed to provide a safe, clean, functional, sanitary, and comfortable environment. This affected one resident (#24) of three residents reviewed regarding environment and the poor condition of the shower chair had the potential to affect 32 of 43 all residents residing in the facility (11 residents received bed baths and did not go to the shower room (#4, #12, #13, #17, #21, #23, #27, #29, #30, #34, and #41) . The facility census was 43. Findings included: 1. Observation on 11/02/23 at 7:48 A.M. of the bedside commode beside Resident #24's bed revealed there was a yellow liquid with an ammonia odor and small brown formed substance in it. The ammonia odor was noted prior to looking in the bedside commode. Observation on 11/02/23 at 9:45 A.M. of the bedside commode beside Resident #24's bed revealed there was a yellow liquid with an ammonia odor and small brown formed substance in it. The ammonia odor was noted prior to looking in the bedside commode. Interview at the time with Resident #24 revealed she didn't use a bedside commode, but her roommate did. She verified it didn't always get emptied and would smell bad at times. Observation on 11/02/23 at 11:12 A.M. of the bedside commode beside Resident #24's bed revealed there was a yellow liquid with an ammonia odor and a small brown formed substance in it. The ammonia odor was noted prior to looking in the bedside commode. Interview on 11/02/23 at 11:15 A.M. with State Tested Nursing Assistant (STNA) #128 revealed she was assigned to the East Hall which included the room Resident #24 and her roommate shared. She reported she did rounds and emptied bedside commodes at least twice a shift and had emptied the bedside commodes on the East Hall this morning. This surveyor asked STNA #128 if she had emptied all the bedside commodes on the East Hall and STNA #128 responded yes. This surveyor and STNA #128 then went to Resident #24's room and observed the yellow liquid with an ammonia odor and small brown formed substance in it. STNA #128 verified she had not emptied Resident #24's roommate's beside commode and should have. 2. Observation on 11/02/23 at 7:48 A.M. of Resident #24's bathroom revealed a brown formed substance on the wall on the left side of the toilet and the string to the call light hanging on the right side of and below the toilet was noted to be dirty and brown. Observation on 11/02/23 at 9:45 A.M. of Resident #24's a brown formed substance on the wall on the left side of the toilet and the string to the call light hanging on the right side and below the toilet was noted to be dirty and brown. Observation on 11/02/23 at 11:12 A.M. of a brown formed substance on the wall on the left side of the toilet and the string to the call light hanging on the right side and below the toilet was noted to be dirty and brown. Observation on 11/02/23 at 11:15 A.M. with State Tested Nursing Assistant (STNA) #128 of a brown (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 3 of 14 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 11/14/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some formed substance on the wall on the left side of the toilet and the string to the call light hanging on the right side and below the toilet was noted to be dirty and brown. STNA #128 verified there was a brown formed substance on the wall on the left of the toilet and the string to the call light hanging on the right side and below the toilet was dirty and brown. Observation on 11/06/23 at 7:30 A.M. of a brown formed substance on the floor under where the one on the wall left side of the toilet was on 11/02/23. The brown formed substance was the same size as the one noted on the wall on 11/02/23. Review of housekeeping checklist, dated 11/02/23 to 11/06 23, revealed Resident #24's bathroom was cleaned daily. Review of the Resident Council Meeting Minutes, dated 08/08/23, revealed housekeeping was not cleaning bathrooms every time. Review of facility policy titled, Infection Control, Housekeeping, revised 03//20, revealed the workplace will be maintained in a clean and sanitary condition, with a schedule of cleaning and decontamination based on the areas of the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area. 3. Observation on 11/02/23 at 7:48 A.M. of Resident #24's ceiling light revealed the light did have a continuous [NAME] when it was turned on and did not emit very much light. Observation on 11/02/23 at 9:45 A.M. of Resident #24's ceiling light revealed the light continued to have a continuous [NAME] when it was turned on and did not emit very much light. An interview at the time with Resident #24 revealed the light had been that way since she was admitted , and it was difficult to see when the light wasn't working. During observation on 11/02/23 at 11:08 A.M. with STNA #128 of Resident #24's ceiling light. She verified the light had a continuous [NAME] and did not provided very much light. Observation on 11/02/23 at 12:45 P.M. with Maintenance Director #126 of Resident #24's ceiling light revealed the light continued to have a continuous [NAME] when it was turned on and did not emit very much light. Interview at the time with Maintenance Director #126 revealed he had not received any notice of the Resident #24's light not working properly. The DON was walking by at the time and reported she had submitted a TELs work order last week regarding the light not working. Maintenance Director #126 verified he had not looked at his work orders. Review of the facility work order titled, Direct Supply TELS, created on 10/27/23 at 10:15 A.M., revealed the DON had completed a request for maintenance to address the ceiling light in Resident #24's room. Interview on 11/02/23 at 2:05 P.M. with Maintenance Director #26 revealed he looked at his work orders in the TELS system on Thursdays or Fridays, but not daily. Review of the Resident Council Meeting Minutes, dated 08/08/23, revealed maintenance was slow at getting things done. 4. Interview on 11/02/23 at 11:22 A.M. with STNA #138 revealed the STNAs clean the shower chairs by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 4 of 14 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 11/14/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm spraying them down with a cleaner and wiping them after the resident shower is complete. She reported that way the shower chairs were ready for the next resident who needed a shower. She revealed the shower chair should be clean and ready for the next resident. Observation of a shower chair at the time revealed it had a brown smeared substance on the seat. STNA #138 verified the shower chair which was prepared for the next resident was actually dirty with a brown substance on the seat. Residents Affected - Some Review of the list provided by the facility revealed eleven residents (#4, #12, #13, #17, #21, #23, #27, #29, #30, #34, and #41) received bed baths and did not go to the shower room for showers. Review of facility policy titled, Infection Control, Housekeeping, revised 03//20, revealed the workplace will be maintained in a clean and sanitary condition, with a schedule of cleaning and decontamination based on the areas of the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area. This deficiency represents non-compliance investigated under Master Complaint Number OH00147907 and Complaint Number OH00147690. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 5 of 14 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 11/14/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, resident record review, facility Self-Reported Incident (SRI) review, time punch documentation and facility policy review, the facility failed to send two State Tested Nursing Assistants (STNAs) home after an allegation of sexual abuse by a resident. This affected one resident (#46) of three residents reviewed for sexual abuse and had the potential to affect Resident #3. The facility census was 43. Residents Affected - Few Findings included: Review of Resident #46's closed medical record revealed an admission date of 10/04/23 with diagnoses including acute cerebrovascular insufficiency, type two diabetes, essential hypertension, hyperlipidemia and male erectile dysfunction. Resident #46 left the faciity on [DATE] against medical advice. Review of Resident #46's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/10/23, revealed the resident had impaired cognition. Further review revealed he was dependent in toileting, personal hygiene and upper body and lower body dressing. Review of Resident #46's progress note, dated 10/16/23 at 5:00 A.M., revealed Licensed Practical Nurse (LPN) #135 documented the patient refused care and used profanity toward the STNA staff when they attempted to change his wet and soiled linens. The nurse spoke with the resident and educated him on the risk of skin breakdown if he refused to allow staff to change his linens. Resident #46 then stated, I will not allow those two girls to touch me, they touched me sexually and inappropriately. Further review of the note revealed the Director of Nursing (DON) and physician were notified. Review of SRI #241215 revealed the alleged sexual assault occurred on 10/16/23 when Resident #46 alleged STNAs #115 and #139 touched him sexually and inappropriately. Review of STNA # 115's time punch revealed she clocked out of the facility on 10/16/23 at 6:15 A.M. and review of STNA #139's time punch revealed she clocked out of the facility on 10/16/23 at 7:04 A.M. Interview on 11/06/23 at 12:42 P.M. with the administrator during review of SRI #241215 verified STNAs #115 and #139 remained in the facility and continued to provide resident care after LPN #135 was informed by Resident #46 of the alleged sexual assault. The administrator verified STNA #115 and STNA #139 should have been sent home. Telephone interview on 11/06/23 at 1:05 P.M. with STNA #115 revealed the accusation of abuse occurred around 5:00 A.M. and she continued to provide care for another Resident (#3), Resident #46's roommate. She reported she clocked out around 6:15 A.M. and left the facility. Telephone interview on 11/06/23 at 1:11 P.M. with STNA #139 revealed the accusation of abuse occurred around 5:00 A.M. and she continued to provide care for another Resident (#3), Resident #46's roommate. She reported she clocked out around 7:00 A.M. and left the facility. She reported she had been mandated to work over until then. Interview on 11/06/23 at 1:30 P.M. with the DON revealed she received a call from LPN #135 on 10/16/23 at 6:20 A.M. regarding Resident #46 reporting alleged sexual abuse from STNAs #115 and #139. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 6 of 14 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 11/14/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON reported she directed LPN #135 to send STNAs #115 and #139 home immediately because that was their policy. Telephone interview on 11/06/23 at 1:33 P.M. with LPN #135 revealed she was made aware of Resident #46 refusing care on 10/16/23 between 5:00 A.M. and 5:15 A.M. by STNAs #115 and #139. She reported she went into Resident #46's room on 10/16/23 at around 5:15 A.M. to discuss with him the importance of getting cleaned up to prevent skin breakdown and at that time he reported that STNAs #115 and #139 had touched him inappropriately/sexually. LPN #135 reported Resident #46 did not appear distressed, and she obtained vitals to make sure there wasn't anything going on medically. She reported his vitals were okay. She reported she then finished what she was doing (medication pass for other residents) when the two STNAs told her Resident #46 would not accept care. LPN #135 reported she gave Resident #46 some time, and then spoke with him again around 6:00 A.M. and his story stayed the same that he had been touched sexually by STNAs #115 and #139. LPN #135 reported she then called the DON and the physician. LPN #135 reported the DON told her to not have STNA #115 or #139 enter Resident #46's room for the rest of the shift. She reported she could not recall the DON telling her to send the STNAs home. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Property, undated, revealed under section VI Protection, the facility recognizes its obligation to keep its residents safe and to protect them from any harm to whatever extent possible and within acceptable standards of practice. Therefore, during an investigation procedures involving resident neglect, abuse, injuries of unknown source and misappropriation of property the follow protocol is utilized: If the alleged abuser is an employee, the employee will be removed from the facility and suspended pending the results of the facility's investigation. This deficiency represents an incidental finding investigated under Complaint Number OH00147881. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 7 of 14 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 11/14/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 tube feeding was labeled when hung, orders for tube feeding were complete, and residents who received tube feedings were weighed appropriately. This affected three residents (#17, #47 and #48) of three residents reviewed for tube feeding. The facility census was 43. Findings included: 1. Review of Resident #17's medical record revealed she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, moderate protein-calorie malnutrition, type two diabetes mellitus without complications, and dysphagia. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/17/23, revealed she was cognitively impaired and had a feeding tube while a resident. Review of Resident #17's physician order, dated 10/13/23, identified she was to receive Diabeta Source enteral feeding every night shift at 80 milliliters (ml)/hour (hr) from 8:00 P.M. to 8:00 A.M. Review of Resident #17's November 2023 Medication Administration Record (MAR) revealed the enteral tube feed Diabeta Source was administered on 11/05/23 at 80 ml/hr from 8:00 P.M. to 8:00 A.M. Review of Resident #17's progress note. dated 11/06/23 at 6:00 A.M., revealed tube feeding was stopped due to 120 ml residual noted. Physician notified of findings and it was okay to turn feeding off a this time instead of 8:00 A.M. No acute gastrointestinal dress noted. Observation on 11/06/23 at 7:40 A.M. of Resident #17 lying in bed. Her tube feeding was not connected to her, and the pump was turned off. The bag of enteral feeding revealed it was Diabeta Source. However, observation at the time revealed no resident name, date or time on the bag when the enteral feed was hung. Observation on 11/06/23 at 8:06 A.M. of Resident #17's tube feeding with the Director of Nursing (DON) revealed a bag of Diabeta Source enteral feeding which did not have a resident's name, date or time on the bag. The DON verified the resident's name should be on the bag of enteral feed along with the date and time the tube feed was hung since a bag of tube feed does have a specific hang time it can be used once it is started. 2. Review of Resident #47's closed medical record revealed he was admitted to the facility on [DATE] to 08/24/23, 09/16/23 to 09/27/23, and readmitted on [DATE] to 10/25/23 with diagnoses including sepsis, malignant neoplasm of the lower third of the esophagus, secondary malignant neoplasm of the brain, and unspecified severe protein-calorie malnutrition. Further review revealed he was discharged from the facility on 10/25/23. Review of Resident #47's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/15/23, revealed he was cognitively intact, had no or unknown weight gain or loss, and was not receiving any type of enteral feeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 8 of 14 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 11/14/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a. Review of Resident #47's physician order, dated 09/19/23 to 09/26/23, identified he was to receive enteral feed every shift at 55 ml/hr via a pump continuously and it may be shut off for one hour a day for personal care. There was no documentation to direct the nurses on what type of enteral formula to administer. Review of Resident #47's September 2023 Medication Administration Record (MAR) revealed he received an enteral tube feed at 55 ml/hr, but the type of enteral formula was not noted. Interview on 11/06/23 at 11:00 A.M. with the DON verified Resident #47 did not have a complete physician order for enteral formula upon admission and should have. She reported the type of enteral formula should have been ordered. She reported the nurses continued what he was on when he was admitted from the acute care facility and did not write a clear order. Review of the facility policy titled, Basic Guidelines for Enteral Feeding, undated, revealed enteral feeding should be delivered by nursing as ordered by the physician. Review of the facility policy titled, Enteral Nutrition Care, undated, revealed confirm that the administration of enteral nutrition is consistent with and follows physician's orders. b. Review of Resident #47's weights the first month of admission revealed he was weighed on 08/10/23 (140.0 pounds) and not again until 09/17/23 (126.0 pounds) with his second admission. There was no documentation to support Resident #47 was weighed the weeks of 08/13/23 and 08/20/23 as he should have been. Interview on 11/06/23 at 11:00 A.M. with the DON verified Resident #47 did not have documented weights for the weeks of 08/13/23 and 08/20/23 and should have. She reported she knew the facility had an issue obtaining weights weekly. Review of the facility policy titled, Weight Policy and Procedure, undated, revealed all new admissions and readmissions will be weighed by the facility within 24 hours of admission and new admissions will be weighed weekly for four weeks after admission. 3. Review of Resident #48's closed medical record revealed she was admitted on [DATE] to 04/13/23, 04/14/23 to 05/14/23, and 05/16/23 to 10/18/23 with diagnoses including cerebral palsy, severe intellectual disabilities, and dysphagia. Further review revealed she was discharged from the facility on 10/18/23 to a group home. Review of Resident #48's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/23/23, revealed she was rarely or never understood. Further review revealed she was receiving parenteral feeding via a nasogastric or abdominal tube while a resident. a. Review of Resident #48's physician order, dated 05/16/23 to 05/23/23, identified she was to receive enteral feed at 35 ml/hr. There was no documentation to direct the nurses on what type of enteral feed to administer. Review of Resident #48's 05/23 MAR revealed she received the enteral tube feed at 35 ml/hr, but the type of enteral feed was not noted. Interview on 11/06/23 at 11:00 A.M. with the DON verified Resident #48 did not have a complete (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 9 of 14 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 11/14/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician order for enteral feed upon admission and should have. She reported the type of enteral feed should have been ordered. She reported the nurses continued what she was on when she was admitted from the acute care facility and did not write a clear order. Review of the facility policy titled, Basic Guidelines for Enteral Feeding, undated, revealed enteral feeding should be delivered by nursing as ordered by the physician. Review of the facility policy titled, Enteral Nutrition Care, undated, revealed confirm that the administration of enteral nutrition is consistent with and follows physician's orders. b. Review of Resident #48's weight the first month of admission revealed she was weighed on 03/22/23 (91.3 pounds) and not again until 04/03/23 (91.3 pounds). There was no documentation to support Resident #48 was weighed the week of 03/26/23 as she should have been. Interview on 11/06/23 at 11:00 A.M. with the DON verified Resident #48 did not have a documented weight for the week of 03/26/23 and should have. She reported she knew the facility had an issue obtaining weights weekly. Review of the facility policy titled, Weight Policy and Procedure, undated, revealed all new admissions and readmissions will be weighed by the facility within 24 hours of admission and new admissions will be weighed weekly for four weeks after admission. This deficiency represents an incidental finding investigated under Complaint Number OH00147628. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 10 of 14 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 11/14/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, resident record review, and facility policy review, the facility failed to ensure a resident was free from unnecessary medication when the resident, who had pain level parameters for the administration of a controlled narcotic, did not receive the medication unless the pain level parameters were met. This affected one resident (#46) of three residents reviewed for medications. The facility census was 43. Residents Affected - Few Findings included: Review of Resident #46's closed medical record revealed an admission date of 10/04/23 with diagnoses including acute cerebrovascular insufficiency, type two diabetes, essential hypertension, hyperlipidemia and male erectile dysfunction. Resident #46 left the faciity on [DATE] against medical advice. Review of Resident #46's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/10/23, revealed the resident had impaired cognition. Further review revealed he had not received any scheduled or as needed pain medications in the last five days. Review of Resident #46's plan of care, dated 10/11/23, revealed he was at risk for an alteration in comfort related to complaints of pain. Interventions included administer medications as ordered to manage pain. Review of Resident #46's physician order, dated 10/05/23, identified he was to receive Norco Oral Tablet 7.5-325 milligram (mg) (a controlled narcotic for pain) one tablet by mouth every six hours as needed for pain, give for pain level seven to ten. Further review revealed a physician order, dated 10/05/23, which identified he was to receive Acetaminophen Oral Tablet 325 mg, give two tablets by mouth every four hours as needed for pain, give for pain level one to six. Review of Resident #46's October 2023 Medication Administration Record (MAR) revealed he received the Norco Oral Tablet 7.5-3.25 mg on 10/06/23 at 4:32 A.M. when he rated his pain a four out of 10; on 10/07/23 at 9:10 A.M. when he rated his pain a six out of 10; on 10/17/23 at 9:23 P.M. when he rated his pain a five out of 10; on 10/20/23 at 4:21 A.M. when he rated his pain a five out of 10 and on 10/20/23 at 9:40 P.M. when he rated his pain a four out of 10. Further review of the October 2023 MAR revealed no acetaminophen was administered on the dates the Norco was given for pain when Resident #46 was having pain which he rated four to six. Interview on 11/07/23 at 2:10 P.M. with the Director of Nursing (DON) verified Resident #46 should have received the acetaminophen order on 10/06/23 at 4:32 P.M., 10/07/23 at 9:10 A.M., 10/17/23 at 9:23 A.M., 10/20/23 at 4:21 A.M. and 10/20/23 at 9:40 P.M. instead of the Norco due to not having a pain level of seven or above. Review of the facility policy titled, Medication Administration, General Guidelines, undated, revealed medications are administered in accordance with written orders of the prescriber. This deficiency represents non-compliance investigated under Complaint Number OH00147881. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 11 of 14 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 11/14/2023 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 medications were administered as ordered by the physician and using standards of care resulting in a medication error rate greater than 5% (error rate of 14.81%). This affected one resident (#26) of two residents observed for medication administration. There were 27 opportunities for medication error and four medication errors resulting in a 14.81% medication error. The facility census was 43. Residents Affected - Few Findings included: Review of Resident #26's medical record revealed she was admitted to the facility on [DATE] with diagnoses including pulmonary embolism, pleural effusion, dysphagia, and type two diabetes mellitus. Review of Resident #26's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/03/23, revealed she was cognitively intact and did not have any coughing or choking during meals, or when swallowing and did not have complaints of difficulty or pain when swallowing. Review of Resident #26's physician orders identified no order for her medications to be crushed. Further review revealed orders for the following medications which should not be crushed due to being extended release or delayed release medications: physician order, dated 09/27/23, identified she was to receive Potassium Chloride ER oral tablet extended release 10 milliequivalent (mEq) by mouth in the morning for a supplement; physician order, dated 11/01/23, identified she was to receive Pantoprazole Sodium Oral Tablet Delayed Release 40 milligrams (mg) by mouth two times a day for gastroesophageal reflux disease; physician order, dated 09/27/23, identified she was to receive Metformin HCL ER oral tablet extended release 24 hours, 500 mg by mouth two times a day for diabetes mellitus; and physician order, dated 09/27/23, identified she was to receive Venlafaxine HCL ER oral capsule extend release 24 hour, 225 mg (one 150 mg capsule and one 75 mg capsule) by mouth in the morning for depression. Observation on 11/02/23 at 8:03 A.M. of Registered Nurse (RN) #109 preparing medications for Resident #26 revealed RN #109 removed all of Resident #26's medications from their containers and proceeded to crush all of the tablets and open all of the capsules except for her two capsules of Creon Capsule Delayed Release Particles. She crushed Resident #26's Potassium Chloride ER oral tablet extended release, Pantoprazole Sodium oral tablet delayed release, and her Metformin HCL ER oral tablet delayed release and opened Resident #26's Venlafaxine HCL ER oral capsule extended release 150 mg capsule and 75 mg capsule. RN #109 then proceeded to mix all the crushed tablets and contents of the open capsules with pudding. RN #109 then administered the pudding with the medications in it and the two Creon capsules whole and in pudding to Resident #26. Review of Resident #26's Medication Administration Record (MAR), dated November 2023, revealed she received the Potassium Chloride ER oral tablet extended release 10 milliequivalent (mEq) by mouth, the Pantoprazole Sodium Oral Tablet Delayed Release 40 milligrams (mg) by mouth, the Metformin HCL ER oral tablet extended release 24 hours 500 mg by mouth, and the Venlafaxine HCL ER oral capsules extend release 24 hour 225 mg by mouth the morning of 11/02/23. Interview on 11/02/23 at 11:42 A.M. with RN #109 verified Resident #26 did not have an order to crush her medications and without an order to crush the medications, they should not be crushed. She also verified Resident #26's Potassium Chloride ER oral tablet extended release, Pantoprazole Sodium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 12 of 14 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 11/14/2023 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 oral tablet delayed release, Metformin HCL ER oral tablet extended release should not have been crushed, and her Venlafaxine HCL ER oral capsules extended release should not have been opened and the contents of the capsules emptied in a cup prior to consumption. Based on all observations of medication administration in the facility, there were 27 opportunities for medication error and four medication errors resulting in a 14.81% medication error. Review of the facility policy titled, Medication Administration, General Guidelines, undated, revealed medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Further review 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 the prescriber: long-acting, extended release or enteric-coated dosage forms should generally not be crushed, an alternative should be sought. This deficiency represents non-compliance investigated under Complaint Number OH00147881. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 13 of 14 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 11/14/2023 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 Dakins Solution half strength used for wound care was dated when opened. This had the potential to affect three residents who had an active skin wound (#13, #24, and #26). The facility census was 43. Findings included: Observation on 11/02/23 at 10:42 A.M. of the wound supply cart revealed one bottle of one-half strength Dakins Solution which was open and almost empty and one bottle of one-half strength Dakins Solution which was open and almost full, each bottle with no documentation on the bottle to note when it was opened. Interview at the time with Registered Nurse (RN) #148 verified the bottles were not dated when opened and they should be. She verified multiple dose bottles expire 30 days after they are opened. Review of the facility policy titled, Medication Storage, Storage of Medication, undated, revealed medication and biologicals are stored properly, following manufacturer or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. This deficiency represents non-compliance investigated under Complaint Number OH00147628. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 14 of 14