Inspection·November 30, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility failed to notify resident physicians and responsible parties when residents tested positive for COVID-19. This affected 11 residents (#2, #22, #27, #33, #40, #44, #66, #69, #77, #89, and #99 ) of 19 residents reviewed for COVID-19. The facility census was 40. Findings included: 1. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, type II diabetes, asthma, and major depression. Review of nursing note from 11/16/23 revealed Resident #66 tested positive for COVID-19, and the resident's physician was not notified. 2. Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, and hypertension. Review of nursing note from 11/17/23 revealed Resident #40 tested positive for COVID-19, but the resident's physician was not notified. 3. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and hypertension. Review of nursing note from 11/20/23 revealed Resident #27 tested positive for COVID-19, but the resident's physician was not notified. 4. Record review revealed Resident #89 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, hypertension, and sleep apnea. Review of nursing note from 11/20/23 revealed Resident #89 tested positive for COVID-19, but the resident's physician was not notified. 5. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, muscle wasting and atrophy, hypokalemia, and hypertension. Review of nursing note from 11/20/23 revealed Resident #44 tested positive for COVID-19, but the resident's physician and responsible party were not made aware. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 365588 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365588 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 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)