Inspection·March 23, 2024

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pull the PICC line and thought he had all the medication the resident needed at home. He was informed that the resident has had medication changes since she had been admitted to the facility. He stated he would take the resident to her regular physician to get her medications she needed. He denied the need of any home health services and would call the facility after 3:00 P.M. if there were any changes. The resident's attending physician was notified on 12/27/24 at 12:42 P.M. of the resident's husband's wishes to have her discharged to home after her appointment. New orders were given for the resident to be discharged home. A nurse's progress note dated 02/28/24 at 8:33 A.M. revealed Resident #46's husband came in last night and got the resident's medications and her discharge paperwork. He informed the facility the urologist said it was okay to discharge her home and her PICC line had been pulled at the office. A review of a medication discrepancy report dated 02/28/24 revealed Resident #46 was discharged from the facility on 02/27/24. The resident's daughter called the facility on that date and reported there was a medication card sent home with the resident that belonged to another resident. The medication card of the other resident was Hyoscyamine 0.125 mg and the resident had been given two doses of that medication in the last 18 hours. They had the resident at the emergency room at that time to be evaluated. Corrective action taken by the facility was to provide education to the nurses on medication errors and discharge planning. Measures taken to prevent recurrence was for two nurses to check all discharge medication. The resident's attending physician was notified of the error and had no concerns about the resident receiving the two doses of Hyoscyamine that was not ordered for her. A review of the facility's investigation file pertaining to the medication error revealed the DON obtained an email response from Agency Nurse #100. The agency nurse informed the DON that Resident #46's family came into the facility on [DATE] at approximately 8:30 P.M. asking to pick up the resident's medications. The agency nurse contacted the DON and was instructed to send all the resident's medications with the husband except for liquid medications. She was also instructed to print off the resident's active medication list and if any narcotics to make sure to get two nurses' signatures and have the resident's husband sign receipt for the narcotic medications. Another nurse was indicated to have counted and verified the narcotics with the agency nurse and printed off the resident's active medication list for the resident's husband. The agency nurse then indicated she provided a bag for the resident's husband to hold while the agency nurse pulled the resident's medications from the medication cart. The nurse claimed she verified the resident's name as she pulled the medications from the cart and placed them in the bag. A review of a training form dated 02/29/24 that was included in the facility's investigation file revealed Agency Nurse #100 received training from the DON on always having two nurses verify a resident's medications upon discharge from the facility. Two nurses were also to sign the discharge papers provided to the resident and/ or family. Additional training had been provided to the department heads on 02/29/24 by the Regional Director of Operations regarding discharge planning and medication errors. A review of a Discharge Review form with an effective date of 02/27/24 at 8:13 A.M. revealed the facility's DON had completed the discharge review for Resident #46. The discharge review had been completed in its entirety and included a list of medications the resident was on at the time of her discharge and instructions for use. The discharge review form indicated the form had been faxed to a local hospital on [DATE], along with a copy of the resident's medication administration record (MAR). A review of a timeline the DON developed, pertaining to Resident #46's discharge and the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 2 of 5 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 03/23/2024 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 0624 Level of Harm - Minimal harm or potential for actual harm error that occurred when her family was given one of another resident's medication, revealed the facility was aware the resident's husband was planning on taking her home after her follow up urology appointment on 02/27/24, if it was approved by the urologist. The DON discussed the resident having medication changes while in the facility and indicated they would have the discharge paperwork and the medications ready for him. Residents Affected - Few On 02/27/24 at 3:32 P.M., the facility's admissions coordinator had called the resident's husband and was informed he was taking the resident home from her doctor's appointment. On 02/27/24 at 8:30 P.M., the resident's husband was indicated to have shown up at the facility and was requesting her medications. The DON confirmed in the timeline that she had been contacted by Agency Nurse #100 and informed her it was okay to give the resident's husband her medications and to also give him a copy of her medications. Agency Nurse #100 was not sure how to do a discharge summary so she printed off the resident's current orders and allegedly discussed all orders with the husband. She then went to the medication cart and pulled the resident's medications out stating she went through them one by one as her husband was holding a bag and she discussed each medication with him before bagging them up. She had another nurse come down and verify the narcotics, but did not verify the other medications she sent home. On 02/28/24 at around 3:50 P.M., the DON indicated in her timeline that Resident #46's daughter called the facility and informed the facility they had a medication card for Resident #37 that contained her Hyoscyamine 0.125 mg. The daughter reported they gave the resident two doses of that medication over the past 18 hours. She then reported the resident had been taken back to the emergency room for unsteady gait and feeling dizzy. The DON had the daughter check all other medications that had been sent home with the resident and that was the only medication that was not intended for her. A review of a written statement by the facility's Administrator dated 02/29/24 revealed she had been informed via a group text at 4:01 P.M. that Resident #46 was not going to be returning to the facility. The group text was about another pending admission and trying to determine if Resident #46 was going to be returning to the facility, after her urology appointment on 02/27/24. The resident's husband was going to come by the facility that evening and get her medications. He did not have some of the medications at home that the resident had been taking at the facility. The Administrator indicated on 02/28/24 at 2:30 P.M., the facility had spoke to the resident's daughter and was requesting to speak with the DON or Administrator. They were informed Resident #46 had received Resident #37's medication (Hyoscyamine) and had taken two doses. The resident was currently in the hospital because she had been lethargic and drowsy throughout the day and had not been doing real well. The daughter reported they did not use the discharge packet to provide medications to the resident but had looked at what was on the medication card and had given her all of the old meds plus the new ones that were provided from the facility. A review of hospital records that was included in the facility's investigation file revealed Resident #46 presented to the emergency department accompanied by her husband. The resident was reporting difficulty with balance with an onset of the evening before. She described the feeling she had as it feeling like the room was spinning. She was also requesting that the PICC line be removed from her right upper arm. Her history and physical from the hospital indicated the resident was released from a nursing facility yesterday just after midnight and returned home. She had medication sent from the facility some of which may have been new but the resident's husband was not sure which ones were new other than the Hyoscyamine, which was written for a different resident. The resident was indicated to have received two doses of that other resident's medication after returning home. The resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 3 of 5 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 03/23/2024 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was normally ambulatory and functional at that time and well in the facility but stated beginning yesterday evening around 10:00 P.M. she had been unable to stand and ambulate. Whenever she tried to stand she would get weak and dizzy. Her mucous membranes were found to be dry and her blood pressure was noted to be low at 94/56 mm/hg. No diagnosis was found as a result of her emergency room visit. A root cause analysis of the incident started on 02/28/24 revealed on the evening of 02/28/24, the DON was notified by Resident #46's daughter that a wrong resident's medication made it home with her mother (Resident #46) and she had taken two doses. The medication was Hyoscyamine 0.125 mg. An interview with the nurse preparing the medication revealed that she went through medications with the husband. Root cause determined to be the facility failed to follow policy and procedure in regards to dispensing home medications to the resident's husband. It was also noted that multiple drug cards were banded together, and that was the way the medications were received from the pharmacy. Although the facility nurse reviewed each medication with the husband, the wrong medication was provided. Two nurses did not review medications per policy. The corrective action taken was re-education completed on 02/29/24. On 03/23/24 at 10:50 A.M., an interview with the DON confirmed there were concerns with Resident #46 being given the wrong medication at the time of her discharge. She reported the resident was having some behaviors the night before her scheduled urology appointment. Her husband came in late to sit with her and decided to take her home. He planned to take the resident to her doctor appointment the following day with the intent to bring her back. After the urology appointment, the resident was released by the urologist. The husband decided at that time that he would just take her home instead of bringing her back to the facility. They asked him about any medications she may need post discharge informing him that some of the resident's medications had changed since she had last been at home. The husband denied needing any at that time and would just get them from her physician. He also declined when asked if he needed home health services set up. He later decided he wanted her medications. When he came to get them, the nurse on duty (Agency Nurse #100) called and asked the DON what she needed to do regarding the resident's medications. She was instructed to give them to him. The medications were to be checked by two nurses. The nurse just had the narcotics verified by two nurses, instead of all her medications like she was supposed to do. There were some extra cards for the resident in the bottom of the medication cart that were banded together. The DON alleged there was a medication card for another resident that was inadvertently wrapped up with Resident #46's extra medications in the bottom of the medication cart that was sent home with the resident. The resident was given two doses of that medication by her family that was ordered for another resident. She believed the medication was ordered for Resident #37 by hospice and was to help with an upset stomach. She could not recall at that time what exactly the medication was, but the resident was given two doses by her husband that caused her to be dizzy. Her attending physician and the hospital physician did not feel the extra medication that was given to the resident that was intended for Resident #37 was the cause of her dizziness. She was asked if Resident #46's discharge from the facility was considered an Against Medical Advice (AMA) discharge or was it a planned discharge. The DON stated the resident was released by the urologist after her follow up appointment. The resident was their for antibiotic treatment for an infection ordered by the urologist and had completed her treatment. Her attending physician at the facility was okay with her release since that was the primary reason she was there. The facility treated it as a medication error at the facility, due to the resident being given the wrong medications at the facility upon her discharge. The agency nurse swore that she went through each medication to verify what was given to the husband when he came to get the medication, but failed to have a second nurse verify the medications she she should have. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 4 of 5 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 03/23/2024 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/23/24 at 2:00 P.M., an interview with Resident #46's husband confirmed they were given a medication belonging to another resident in with the medications that he picked up from the facility on 02/27/24 for Resident #46, after her discharge from the facility. He verified he had taken the resident home after her follow up urology appointment and knew she had some new medications that he did not have the prescriptions for. He was told the facility had her medications on hand and he should come in and pick them up. He was not sure what nurse he interacted with that night when he picked up the resident's medications. He denied he was in a rush when he came to get the medications and had time to go through a proper discharge process if necessary. They had provided him some information (her face sheet and a list of medications) to take with the resident for her follow up urology appointment. He denied he received any type of discharge paperwork when he came in to get her medications later that evening. He also denied that he had refused to take any discharge paperwork when he came in to pick up the medications that may have been offered. He reported the the nurse went through the medication cart and pulled out everything she thought was the resident's placing them in a big bag. He denied she reviewed each medication with him as was alleged in the facility's investigation, but believed she looked at the labels when pulling them out of the cart. The only medications that were banded together were the resident's narcotic medications. The other medication cards were loose in the bag to include the other resident's medication that had erroneously been given to them. He was not sure what the medication was that belonged to the other resident but it was given to the resident as they believed it was hers since the facility gave it to them. He confirmed they took the resident to the hospital the day after she was discharged from the facility for being weak and dizzy. The hospital did not find anything wrong with her and did not think the medication given to her in error would have caused her any problems. The facility's policy on Discharge Medications (dated October 2007) revealed medications were sent with the resident upon discharge on ly under conditions that protect the resident and assure compliance with applicable state laws. The labels of discharge medications were verified for completeness and accuracy by checking them against the most recent prescriber's orders. The telephone number of the provider pharmacy was given to the resident or responsible party to use in the event that additional information was needed regarding medication therapy. Discharge medication information was entered on the discharge instructions form or continuity of care form. This deficiency represents non-compliance investigated under Complaint Number OH00151896. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365588 If continuation sheet Page 5 of 5