Inspection·December 27, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hip for complaints of pain. The x-ray results showed an acute left hip fracture. The on-called Certified Nurse Practitioner (CNP) #502 was updated on results and order given to send to the emergency room for evaluation. The Power of Attorney (POA) was updated on and agreeable with decision. Regional emergency management services (EMS) were notified. Interview on 01/30/24 at 12:02 P.M., with RN #163 and the Director of Nursing (DON) revealed the resident had fallen around 12:30 A.M. The resident had no visible signs of injuries, however the resident verbalized pain and had facial grimacing with movement. He attempted to call the on-call provider a few times but had to leave a message with on-call answering services. The on-call APRN did not return his call until around 6:30 A.M. The RN reported he did not know how to handle the situation because he was an emergency nurse, and this was new to him. He did not know who the medical director was until today and he did not have his number to call him. The RN also reported he did not reach out to the DON or nursing supervisor when he was not able to reach a provider for guidance. The RN confirmed the fall was not documented in the resident's electronic medical record. The interview was reviewed with the RN and DON to confirm accuracy of the interview. The RN confirmed the accuracy of the interview. Interview on 01/30/24 at 12:03 P.M. and 1:02 P.M., with the DON revealed RN #163 should have called herself or the medical director when the on-call provider did not return his call timely. The DON reported the medical director's number was in the rolodex and staff had been educated on notification as part of the plan of correction for the surveyor that was completed on 12/27/23. The DON confirmed the change of condition log, which was part of the facilities plan of correction, included falls, skin, etc. did not include Resident #5's fall due it did not trigger the 24 hour report due the nurse not documenting the fall in the residents medical record. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 2:07 P.M., with the DON revealed the facility uses an on-call provider system after hours. The Medical Director #500 and Physician #501 were a part of the on-call system. As part of the plan of correction for the Immediate Jeopardy that the facility received on 12/27/23 was if there was urgent issue the nurse was to ensure the provider would respond in 20 minutes and if was a non-urgent issue the staff were to keep trying to call. The resident (Resident #5) that had a suspected fracture and needing an x-ray would have been an urgent issue. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 3:11 P.M. with the Administrator revealed the on-call system was a group of providers that cover for one another. Some of the provider due not provided services to the residents except for answering the on-calls that come in. Sometimes the providers will answer calls and sometimes it will go to an answering service, and the answering service would contact the one call provider. The facility except the provider to call back within 20 minutes if there was an adverse effect. Resident #5's fall with possible fracture suspected would be an example of an adverse event. The nurse should notify the family or send the resident to the emergency room if an adverse event occurs and the provider doesn't return a call. The interview was reviewed with the Administrator to confirm accuracy of the interview. The Administrator confirmed accuracy of the interview. Review of the facility policy for falls management (dated 10/2023) revealed the nurse must notify the physician promptly by telephone. The nurse must notify the physician if any injury is obtained. Review of staff education (dated 05/08/23 and 05/12/23) revealed when a resident has a change of condition you would need to notify the physician or the practitioner on call. Physician #501 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 2 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communication book at each nurse station with instructions on how to contact a practitioner. If you are unable to reach a practitioner, then you have to contact the Medical Director and his phone number will be in the rolodex at each nurse's station. If you were unable to get hold of any of the above, contact the family and send them to the emergency department. Notify the nursing if the practitioner did not respond. Review of the communication book/form for Physician #501 (Resident #5's physician) (undated) revealed please contact the Advance Practice Registered Nurse (APRN) between 3-4:00 P.M. with all issues and as needed for emergent issues only from 6:00 A.M. to 8:00 P.M. Please see the guidelines for provider notification in the communication book. Monday through Friday 8:00 P.M. to 6:00 A.M. and Saturday, Sundays and Holidays call the office answering services (number listed) for the on call APRN. Do not call or fax the office unless directed to do so (numbers were listed). Additional form in the communication book dated 06/2023 titled After Hours Provider Notification Protocol(8:00 P.M. to 6:00 A.M. weekday, all day on holidays and weekends) revealed the objective was to provide timely, efficient, safe, appropriate patient care by ensuring a thorough situation evaluation before contacting after-hours, on call providers. Purpose: The on-call provider's coverage is to be used for urgent issues that cannot wait until the next day a provider is in the facility or for a daytime call to the managing Advanced Practice Nurse. The federal regulation regarding Notification of Changes (F517) speaks to the immediate notification which included any significant change any significant change in physical or mental status from baseline. This document was meant to use as a guide and not to replace the need for appropriate discernment to call either 911 or to contact the on-call team in the event the situation was unclear, and the patient was unstable. Included in the communication book was a checklist titled Guideline for Provider Notification dated 06/2023 revealed immediate notification would be a change in condition/mental status, fall with injury requiring further evaluation and treatment and abnormal x-ray (symptomatic and requiring treatment). Review of the facility audits and tracking log for change of condition (part of the Immediate Jeopardy removal plan) dated 12/20/23 to 01/29/24 revealed no evidence of Resident #5's fall with major injury was noted on the log. The tracking form included resident name, change of condition, name of practitioner notified, POA notified, documented, and signature of DON or designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 3 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, interviews, and facility policy review, the facility failed to provide timely and necessary care and treatment to prevent complications following a fall with injury and changes in resident condition. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] when Resident #2 sustained a fall with his left arm assessed to have an area that was raised, red, and warm to touch between his ulna and humerus bone without evidence of additional medical treatment. Between [DATE] and [DATE] Resident #2 continued to exhibit changes in condition including his arm being red, edematous, warm, and tender to touch, Resident #2 was lethargic and experienced episodes of decreased appetite, elevated body temperatures, and decreased oxygen saturation levels. The facility failed to seek medical treatment for Resident #2 until [DATE] (five days later), when Resident #2 was transported to the emergency room (ER). Resident #2 was admitted to the intensive care unit (ICU) with diagnoses of cellulitis and related septic shock. Resident #2 required Levophed (a potent vasoconstrictor used to treat hypotension) intravenous (IV) and IV antibiotics. Resident #2 was hospitalized for four days, returning to the facility on [DATE]. The Immediate Jeopardy and actual harm continued on [DATE] at 1:50 A.M. when Resident #2 was found to be foaming at the mouth with a decreased level of consciousness, and was cold and clammy, lethargic, and difficult to arouse, with a decreased oxygen saturation of 71% on room air, an elevated respiratory rate of 28 and a decreased blood glucose level of 23 milligrams per deciliter (mg/dl) (per the Centers for Disease Control, a blood glucose level below 70 mg/dl is considered hypoglycemia). Glucagon was administered via intramuscular (IM) injection. After 15 minutes, Resident #2's blood glucose level was 66. On [DATE] at 4:05 A.M., Resident #2's blood glucose level was 47 and a second dose of Glucagon IM was administered. After 15 minutes, his blood glucose level was 38 and a third dose of Glucagon was administered. Resident #2 was then administered half packet of oral glucose gel and given orange juice, which resulted in a glucose level of 68. Resident #2 was transferred to the ER by Emergency Medical Services (EMS) at 6:15 A.M. (over four hours after the change in condition was first identified). Resident #2 was admitted to the intensive care unit (ICU) with diagnoses of worsening (left upper extremity [LUE]) cellulitis and severe sepsis. Resident #2 did not return to the facility and expired on [DATE]. Residents Affected - Few Additionally, a concern that did not rise to an Immediate Jeopardy occurred when facility staff failed to adequately monitor and report (to the physician) episodes of hyperglycemia for Resident #1 to properly manage the resident's diagnosis of diabetes mellitus. This affected two residents (#1 and #2) of three residents reviewed for change in condition. The facility census was 77. On [DATE] at 5:20 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when facility staff failed to timely identify and obtain medical treatment for Resident #2 following an acute change in condition. The facility failed to seek adequate and necessary treatment until [DATE] when Resident #2 was transferred to the emergency room and admitted with cellulitis and related septic shock. Following Resident #2's return to the facility, on [DATE] at 1:50 A.M. the resident exhibited an acute change in condition but was not transferred to the emergency room until 6:15 A.M. (over four hours later) where he was admitted with worsening (LUE) cellulitis and severe sepsis. Resident #2 did not return to the facility and expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 4 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 On [DATE] the facility initiated a Performance Improvement Plan (PIP)/Quality Assurance Performance Improvement (QAPI) for skin prevention. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE], the DON and Interdisciplinary Team (IDT) reviewed the skin care policy and no changes were made. • On [DATE], the DON conducted an investigation concerning physician response during Resident #2's change of condition on [DATE]. • On [DATE], the DON spoke with Resident #2's physician and voiced concern the on-call practitioner did not respond during a change of status for Resident #2. The practitioner stated that he would look into why no one responded. • On [DATE], the DON then contacted the [NAME] President of Nursing for the facility and the facility Medical Director via a conference call. • On [DATE], the DON devised a plan of correction (POC) for physician notification with a change of condition. • On [DATE], the staff nurse involved in the hypoglycemia incident was educated by the DON on the incident and facility POC. • On [DATE], the rolodex on each nurse's unit was updated by the DON with the medical director's name and phone number. • On [DATE], a secure conversation was sent out to all nurses' regarding physician notification by the DON, after the message was read, each nurse had to respond through PointClickCare (PCC) to the DON that the message was received and read. • On [DATE], the DON and wound nurse completed small huddles with nurses and State-Tested Nursing Assistant (STNA) staff regarding importance of preventable skin measures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 5 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 • Level of Harm - Immediate jeopardy to resident health or safety On [DATE], the facility wound nurse began tracking all skin issues such as, skin tears, abrasions, rashes, etc. The wound nurse would notify the practitioner of new wounds and change in wounds, weekly and as needed. She also would notify the resident power of attorney (POA) weekly of wound status and any changes, unless the POA did not want weekly updates, then it would be documented how often POA would like to be notified. Residents Affected - Few • On [DATE] to [DATE], the DON reviewed one-on-one with all professional nurses, the facility skin care policy. • On [DATE] and [DATE] the DON conducted official meetings with all nurses addressing physician notification during resident change of status, skin integrity/wounds, falls/injuries, assessments and documentation. The meeting was mandatory with all nurses present on either [DATE] or [DATE]. • On [DATE], the IDT met for the first monthly meeting to discuss skin issues and concerns, as well as compare if skin issues improved or worsened for one year. • On [DATE] and [DATE], skin sweeps for all residents with the wound nurse and wound practitioner were conducted. Findings were documented in the resident's medical record. If any open areas or concerns, treatments were initiated and POA's were notified. • On [DATE], a plan for weekly skin sweeps to be completed by the staff nurse on duty for the shift and day the skin sweep was scheduled. • On [DATE], the facility performance improvement plan (PIP) was evaluated by the IDT and facility continued with the current interventions put in place. It was discussed that the IDT would review with the Medical Director compliance and barriers regarding skin assessments during quarterly Quality Assurance (QA) meetings, discussing standards in practice and utilizing any guidance. The facility wound nurse would present findings and initiate any PlP's according to QA discussion. • On [DATE], the DON developed a tracking tool to review resident charts to ensure physicians were being notified promptly and resident change of condition was being addressed promptly. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 6 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE], the facility implemented a plan for the DON and /or assigned designee to review the 24-hour report in PCC daily to review documentation for any change of status and ensure physician notification was being completed in a timely manner. • On [DATE], the facility implemented a plan for the DON and/or designee to address any concerns promptly with the staff, should a concern arise. • The IDT will review with the Medical Director compliance and barriers regarding change of condition and physician notification during quarterly QA meetings, discussing standards in practice and utilizing any guidance. The DON would present findings and initiate any PIP's according to QA discussion. • On [DATE], a facility Quality Assessment Performance Improvement (QAPI) plan was developed. • On [DATE], a tracking log was developed to track blood sugars (BS) of all diabetics to ensure that a practitioner had been properly notified (based on physician orders or facility policy parameters). • On [DATE], the facility implemented a plan for the DON and/or designee to audit BS results daily for one year then as needed to ensure physician was notified and policy and procedure followed. If any concerns were observed during the auditing process they would be addressed promptly by the DON and/or designee, as well as education to involved staff. • The IDT will review with the Medical Director compliance and barriers regarding Blood Sugar Policy and Procedure during quarterly QA meetings, discussing standards in practice and utilizing any guidance. The DON will present findings and initiate any PIP's according to QA discussion. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the closed medical record for Resident #2 revealed an initial admission date of [DATE] with diagnoses including mild cognitive impairment, diabetes mellitus, chronic kidney disease, atherosclerotic heart disease, anxiety disorder, and muscle weakness. Review of the medical record revealed Resident #2's physician was Physician #400. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 7 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #2's care plan, dated [DATE], revealed the resident had diabetes mellitus with interventions including to administer insulin per physician orders, monitor/document/report as needed any side effects and/or effectiveness; and to check all body for breaks in skin and treat promptly as ordered by the physician. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #2 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine. The assessment revealed Resident #2 required limited, one-person assistance from one staff for bed mobility, transfer, walking corridor, toileting, and personal hygiene. The assessment further indicated the resident sustained one fall since admission/re-entry or prior assessment with no major injury. The resident had no pressure ulcers or other ulcers, wounds, or skin problems. The resident was continent of bowel and bladder. Review of the nursing progress note, dated [DATE] at 9:30 P.M., revealed Resident #2 was found sitting on the floor with his back against his bathroom door. Vital signs were not within normal limits (WNL) with an oxygen (O2) saturation bouncing around in the 70's, blood pressure (BP) 80/62 (hypotensive), and temperature 98.9 degrees F. The resident's left arm was observed to be raised, red, and warm to touch between his ulna and humerus bone. The resident was noted to be incontinent of bowel movement (BM) at the time of the fall. The physician was notified, and an x-ray was ordered for the left arm. The physician instructed the nurse to continue to monitor the resident closely. Review of the nursing progress note, dated [DATE] at 12:32 P.M., revealed Resident #2 was very lethargic during the shift. His O2 saturation was 86% on room air and oxygen was applied at 2 liters (L) per nasal cannula. The resident was very non-compliant with leaving the nasal cannula on. The resident complained of pain to the LUE and Tylenol was administered. There was no documented evidence that the resident's physician was notified of the low oxygen saturation and complaint of LUE pain. Review of the Medication Administration Record (MAR), dated [DATE], revealed Tylenol 650 milligram (mg) suppository was administered on [DATE] at 1:14 A.M. for a temperature of 100.6 degrees F. Review of the post-fall 72 Hour Neurological assessment dated [DATE] at 1:00 A.M. revealed Resident #2 was hypotensive with a blood pressure (BP) of 89/63. At 5:00 A.M. the resident's BP was 86/58 (hypotensive). There was no documented evidence the resident's physician was notified of the resident's hypotension or that the resident was transferred to the emergency room for evaluation/treatment. Review of the nursing progress note, dated [DATE] at 10:29 A.M., revealed Resident #2's left forearm was red, warm, swollen, and painful to the touch. The nurse's note revealed the resident's physician was updated at that time. A physician's order, dated [DATE], revealed an order for the antibiotic, Clindamycin HCL 300 milligrams (mg) one capsule, three times per day, for cellulitis of the left arm. The physician also provided an order, on [DATE] to cleanse left wrist laceration with normal saline and apply a Vaseline gauze and foam patch each day shift. Review of the Treatment Administration Record (TAR), dated [DATE], revealed the order (obtained [DATE]) to cleanse left wrist laceration with normal saline and apply a Vaseline gauze and foam patch was not initiated until [DATE]. Review of the nursing progress notes revealed Resident #2 sustained two additional falls without injury on [DATE] and [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 8 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the Medication Administration Record, dated [DATE], revealed on [DATE] at 5:00 P.M., Resident #2's blood glucose was 315 and on [DATE] at 8:00 A.M., the blood glucose was 361. There was no documented evidence of the physician being notified of the resident's blood glucose levels greater than 300 per the facility's policy (for hyperglycemia). Review of the nursing progress note, dated [DATE] at 12:54 P.M., revealed Resident #2's left arm remained edematous, red, and warm to touch. The resident required two-person assistance with activities of daily living (ADL) and was incontinent of bowel and bladder. There was no documented evidence that the resident's physician was notified of the continued edema, redness, and warmth of the left arm, continued bowel incontinence, or of the resident's decline in ADL status. There was no evidence the resident was transferred to the emergency room for evaluation/treatment at this time. Review of the nursing progress note, dated [DATE] at 6:10 P.M., revealed Resident #2's left arm continued to be edematous and tight, red, and warm to touch. Inside elbow skin is sloughed off and red, moist skin under. The resident was lethargic. There was no documented evidence that the resident's physician was notified of the continued edema, tightness, redness, warmth, and skin sloughing of the left arm or that the resident was transferred to the emergency room for evaluation/treatment at this time. Review of the nursing progress note, dated [DATE] at 10:07 A.M., revealed Resident #2 refused breakfast and his left arm remained red, warm, edematous, and tender to touch. The dressing was changed to the left wrist wound. There was no documented evidence that the resident's physician was notified of the continued edema, redness, and warmth of the left arm or that the resident was transferred to the emergency room for evaluation/treatment at this time. Review of the nursing progress note, dated [DATE] at 7:28 P.M., revealed Resident #2 was lethargic and difficult to arouse. Cellulitis to the left arm was worsening and he was unable to take oral medication. Resident #2's BP was 72/42 (hypotensive), pulse 62, respirations 24, temperature 99.9 F, and O2 saturation was 65% (low). The resident's fingers were cold with poor circulation noted. At 4:00 P.M., the resident's blood glucose level was elevated at 232 and his insulin held because the resident had not eaten anything all day and drank very little. The physician was notified at that time and the note indicated the nurse was awaiting a return call. Review of the nursing progress note, dated [DATE] at 7:47 P.M., revealed Resident #2 was transported to the ER by EMS. Review of hospital records, dated [DATE], revealed Resident #2 presented with hypotension and a swollen left arm and forearm and was diagnosed with cellulitis and septic shock. IV fluids and antibiotics per sepsis protocol were initiated in the emergency department (ED). The resident required Levophed IV, a potent vasoconstrictor used to treat hypotension and was admitted to the intensive care unit (ICU) until [DATE]. Review of the nursing progress note, dated [DATE] at 4:30 P.M., revealed Resident #2 returned from the hospital and was re-admitted to the skilled nursing facility. Review of the physician order, dated [DATE], revealed the order for the antibiotic, Augmentin oral tablet 875-125 mg, one tablet every 12 hours for seven days, for cellulitis. Review of a nursing progress note, dated [DATE] at 7:42 P.M., revealed Resident #2 refused his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 9 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety antibiotic Augmentin. There was no documented evidence of the physician being notified of the resident's medication refusal. Review of the Medication Administration Record, dated [DATE], revealed on [DATE] at 5:00 P.M. the resident's blood glucose was 332. There was no documented evidence of the physician being notified of the resident's blood glucose levels greater than 300 per the facility's policy. Residents Affected - Few Review of a nursing progress note, dated [DATE] at 1:50 A.M., revealed Resident #2 was found to be foaming at the mouth with a decreased level of consciousness, and was cold and clammy, lethargic, and hard to arouse. His O2 saturation was 71% on room air and his respiratory rate was 28. An attempt to notify the physician was unsuccessful. Resident #2's blood glucose level was 23 mg/dl (per the Centers for Disease Control, a blood glucose level below 70 mg/dl is considered hypoglycemia) and Glucagon was administered via IM injection. After 15 minutes, at 2:10 A.M. the resident's blood glucose level was 66. At 2:45 A.M., the blood glucose level was 68. Review of a nursing progress note, dated [DATE] at 4:05 A.M., revealed Resident #2's blood glucose level was 47 and a second dose of Glucagon IM was administered. After 15 minutes, his blood glucose level was 38 and a third dose of Glucagon was administered. The resident was then administered half packet of oral glucose gel and given orange juice, which resulted in a glucose level of 68. Further attempts to notify the physician were unsuccessful. The POA was called at 6:15 A.M. and Resident #2 was transferred to the ED by EMS at 6:30 A.M. Review of the hospital history and physical, dated [DATE], revealed Resident #2's chief complaint was worsening shortness of breath and low blood sugar. The resident's white blood cell count was 13.9 (elevated). The LUE had cellulitis from the distal forearm to the proximal humerus with ulcerations noted in the area. The assessment revealed LUE cellulitis, dementia, septic shock, and bilateral pneumonia. The resident did not return to the facility following this hospitalization and expired on [DATE]. Interview on [DATE] at 2:40 P.M., with Registered Nurse (RN) #124 confirmed she authored the nursing progress note, dated [DATE] at 11:46 A.M., which revealed Resident #2 had a left wrist laceration with thick, yellow drainage in the wound bed and redness and warmth was noted in the peri-wound. RN #124 confirmed she did not obtain wound measurements or notify the physician of the thick, yellow drainage to obtain adequate and necessary medical treatment. Interview on [DATE] at 11:15 A.M. with the DON confirmed a thorough skin/wound assessment, including wound measurements, was not completed for Resident #2's left, open wrist wound, nor was there a comprehensive assessment of the LUE cellulitis. The DON confirmed the physician should have been updated regarding any changes of condition or worsening of Resident #2's cellulitis. The DON further confirmed the facility had identified an issue related to Resident #2's incidents of hypoglycemia on [DATE] and the lack of physician response when notification was attempted. The DON stated the nurse should have contacted the resident's POA and sent Resident #2 to the hospital sooner for evaluation when she could not reach the physician. Interview on [DATE] at 12:39 P.M. with Physician #400 revealed he was not notified of Resident #2's continued LUE redness, swelling, edema, and pain following the initiation of the antibiotic Clindamycin. Physician #400 stated that without proper skin assessments, the nursing staff would have been unable to determine if the infection was spreading despite the treatment plan. Physician #400 further stated while he was not sure if anything additional could of have been done in the outpatient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 10 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few setting, he would have sent the resident to the hospital (sooner) and properly adjusted the treatment plan. Physician #400 stated the resident's cellulitis contributed to septic shock because the antibiotic Clindamycin was not strong enough and the patient was not responding and needed IV antibiotics and IV fluids to get out of harm's way. Review of the facility policy titled, Non-Pressure Related Skin Assessment Policy and Procedure, dated [DATE], revealed document any non-pressure skin impairments, notify the physician, initiate treatment and document on the Treatment Administration Record (TAR), notify the family, and evaluate the treatment and effectiveness of treatment, update the physician as needed. Review of the facility policy titled, Blood Sugar Policy, revision date [DATE], revealed the following protocol would be followed concerning blood sugar results by an outside lab, assisted living, or nursing home monitoring system. Hypoglycemia: Administer 15 grams of carbohydrates for a blood sugar below 60 mg/ml and the resident is still alert. Recheck the blood sugar. If hypoglycemic symptoms continue, treat again with carbohydrates. If the hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. If the resident was unresponsive due to hypoglycemia, administer Glucagon one mg IM per standing order. If hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. Hyperglycemia: Notify the attending or on-call physician for a blood sugar reading of 300 mg/ml or higher unless physician has given specific blood sugar parameters. Examples of 15 grams of carbohydrates: four ounces of a sugar free supplement, four ounces of orange juice, or one dose of Glutose 45 (a fast-acting glucose gel). 2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, diabetes mellitus, anxiety, dysphagia, and chronic kidney disease. Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident could not be interviewed. The assessment revealed Resident #1 was dependent on staff with assistance for eating, toileting, and personal hygiene. The assessment further revealed the resident was always incontinent of bowel and bladder. Review of Resident #1's care plan, dated [DATE], revealed an intervention for fingerstick blood glucose monitoring per physician order/facility policy and as needed and to notify the physician of blood sugar reading below or above specified physician order/facility policy values. Review of the Medication Administration Record, dated [DATE] and [DATE], revealed on [DATE] at 5:00 P.M., Resident #1's blood glucose was 341, on [DATE] at 5:00 P.M., Resident #2's blood glucose was 355, on [DATE] at 5:00 P.M., the blood glucose was 385, on [DATE] at 5:00 P.M., the blood glucose was 305, on [DATE] at 5:00 P.M. the blood glucose was 312, and on [DATE] at 5:00 P.M. at the blood glucose was 420. There was no documented evidence of the physician being notified of Resident #1's blood glucose levels greater than 300 per the facility's policy. Interview on [DATE] at 3:40 P.M. with the Director of Nursing (DON) confirmed Resident #1's physician was not notified of blood glucose levels greater than 300 on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] as indicated in the facility's policy resulting in the resident's diabetes mellitus not being properly managed and monitored. Review of the facility policy titled, Blood Sugar Policy, revision date [DATE], revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 11 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few following protocol would be followed concerning blood sugar results by an outside lab, assisted living, or nursing home monitoring system. Hypoglycemia: Administer 15 grams of carbohydrates for a blood sugar below 60 mg/ml and the resident is still alert. Recheck the blood sugar. If hypoglycemic symptoms continue, treat again with carbohydrates. If the hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. If the resident was unresponsive due to hypoglycemia, administer Glucagon one mg IM per standing order. If hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. Hyperglycemia: Notify the attending or on-call physician for a blood sugar reading of 300 mg/ml or higher unless physician has given specific blood sugar parameters. Examples of 15 grams of carbohydrates: four ounces of a sugar free supplement, four ounces of orange juice, or one dose of Glutose 45. This deficiency represents non-compliance investigated under Complaint Number OH00148970. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 12 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure Resident #2 had a physician order for oxygen therapy. This affected one (Resident #2) of three residents reviewed for respiratory care. The facility census was 77. Residents Affected - Few Findings include: Review of the closed medical record for Resident #2 revealed an initial admission date of 11/07/22 with diagnoses including mild cognitive impairment, diabetes mellitus, chronic kidney disease, atherosclerotic heart disease, anxiety disorder, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/09/23, revealed Resident #2 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine. The assessment revealed Resident #2 required limited, one-person assistance from one staff for bed mobility, transfer, walking corridor, toileting, and personal hygiene. Review of Resident #2's physician orders prior to 04/14/23 revealed no orders for the administration of oxygen therapy. An order for oxygen was given on 04/14/23 and indicated oxygen at 2 liters per minute as needed (prn) for shortness of breath for three days. Review of the nursing progress note, dated 04/04/23 at 9:30 P.M., revealed Resident #2 was found sitting on the floor with his back against his bathroom door. Vital signs were not within normal limits (WNL) with an oxygen (O2) saturation bouncing around in the 70's, blood pressure (BP) 80/62, and temperature 98.9 degrees Fahrenheit (F). O2 at five liters (L) infused per nasal cannula (NC). Review of the nursing progress note, dated 04/05/23 at 12:32 P.M., revealed Resident #2's O2 saturation was 86% and oxygen was infusing at 2 L per NC. Review of the nursing progress note, dated 04/09/23 at 7:28 P.M., revealed Resident #2's O2 saturation was 65% and oxygen was infusing at 2 L per NC. Interview on 12/18/23 at 11:15 A.M. with the Director of Nursing (DON) confirmed Resident #2 received oxygen therapy on 04/04/23, 04/05/23, and 04/09/23 without a physician's order. This deficiency represents non-compliance investigated under Complaint Number OH00148970. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 13 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of risk management report, review of hospital records, interview, and policy review the facility failed to implement an effective pain management program for one resident (Resident #5) after sustaining a fall with fracture. This affected one (#5) of three residents reviewed for change of condition. Residents Affected - Few Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, chronic pain, polyosteoathritis, generalized anxiety, age-related osteoporosis without current pathological fracture, and repeated falls. There was no evidence the diagnoses list was updated to include the acute left hip fracture and left superior pubic ramus fracture that occurred on 01/27/24. Review of Resident #5's quarterly Minimum Data Set (MDS) 3.0 dated 10/21/23 revealed the resident's speech was unclear and had minimal difficulty hearing. She could sometimes make herself understood and sometimes understood others. She had impaired vision and no corrective lenses. The resident's brief interview for mental status (BIMS) score was three, which indicated she had severe cognition impairment. The resident had inattention and disorganized thinking behaviors that fluctuated (comes and goes, changes in severity). The resident was dependent on staff for all activities of daily living except when she required substantial/maximal assistance with eating. The resident was always incontinent of urine and bowel. The resident was on a scheduled pain manage regimen; however, a pain assessment interview was not conducted due to the resident being rarely/never understood. The staff pain assessment was not completed as well due to there being no signs or symptoms of pain observed or documented. Resident #5 had two falls with no injuries since the last admission/entry. The resident was marked to be on high-risk drug classes of antianxiety and antidepressants. The resident used a manual wheelchair. Review of Resident #5 chronic pain plan of care initiated on 07/15/20 and revised on 11/23/22 related to fibromyalgia and polyosteoathritis revealed to plan heavy care when pain was controlled, administer Biofreeze, Gabapentin, Tylenol, and Percocet per physician orders and monitor/document/report as needed for any side effects and or effectiveness (revised on 01/30/24), consult pain management, monitor/report/record to nurse any sign or symptoms of non-verbal pain (changes in breathing, vocalization, mood/behavior, eyes, face, body), offer rest periods as indicated. Review of Resident #5's risk management report form (not part of the medical record) dated 01/27/24 at 12:30 A.M. authored by Registered Nurse (RN) #163 revealed this RN was called to the resident room by State Tested Nurse's Aide (STNA). The resident was sitting on the floor next to the bed. Resident vitals were taken at this time (temperature was 97.7, respirations were 18, oxygen saturation was 94% room air, heart rate 89, and blood pressure was 174/87). Resident was alert to self. Pupils equal, round, reactive, light, and Accommodation (PERRLA). No visible injury was noted at this time. Resident complains of left hip pain. Resident stated that she was trying to get to the bathroom. The resident denied hitting her head. Reminded resident not to attempt to get out of bed without assistance. Pain level was a 10 and she was alert and oriented to the person only. Unable to determine the injury type but the location was in the left gluteal fold. The resident was noted to be wheelchair bound. There were no environmental factors noted. The predisposing physiological factors included the resident was confused, incontinent, and had gait imbalance. The predisposing factors indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 14 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident ambulated without assist. The on-call service was notified at 12:40 A.M. and the power of attorney (POA) at 12:41 A.M. At the bottom of the fall investigation report form it indicated the report was privileged and confidential - not part of the medical record- do not copy. Review of Resident #5's electronic medical record dated 01/22/24 to 01/30/24 revealed no evidence of details of the fall including provider notification, time of fall, assessment, orders, etc. regarding the resident's fall on 01/27/24. Review of Resident #5's x-ray results dated 01/27/24 at 1:37 P.M., revealed a nondisplaced fracture of the left intertrochanteric region was noted. A mildly displaced left superior pubic ramus fracture was noted. Diffuse osteopenia was noted. Impression acute left hip fractures of the left superior pubic ramus fracture. Review of Resident #5's hospital notes dated 01/27/24 revealed the x-ray showed acute moderately displaced left intertrochanteric proximal femur fracture and acute moderately displaced fracture of the left superior and inferior pubic rami. The resident's face pain assessment for the left hip was 10 out of 10 at 3:12 P.M and 3:50 P.M. The resident was given intravenous Fentanyl and Zofran for pain. The left leg was shortened and rotated. The resident had lumbar pain and neck pain and c-collar was applied. The discharge instruction was to call Physician #501 in one day for palliative care due to the resident being a surgical candidate. The final diagnoses was closed traumatic displaced intertrochanteric fracture of left femur and closed fracture of multiple rami of left pubic. Review of Resident #5's current orders dated 01/2024 revealed on 01/27/24 the resident was ordered Percocet 5/235 milligrams (mg) every six hours as needed for pain. On 11/23/20 she was ordered Tylenol Extra Strength 500 mg and by mouth twice daily for pain and two every 8 hours as needed for pain. Also, on 11/23/20 was an order for Gabapentin 100 mg one capsule twice a day and two at bedtime for pain. Review of Resident #5's medication administration records (MAR) dated 01/27/24 to 01/31/24 revealed the resident had received one dose of Percocet 5-325 mg on 01/27/24 at 9:52 P.M. for a pain level of 3 out of 10, three doses on 01/28/24 (3:52 A.M. pain level two out of 10, noon for pain level of eight out of 10, 6:06 P.M. for pain level four out of 10), three doses on 01/29/24 (6:16 A.M. for pain level one out of 10, 12:20 P.M. for pain level eight out of 10, and 9:40 for pain five out of 10) and three doses on 01/30/24 (4:55 A.M. for pain level of eight out 10, 11:05 A.M. for pain level of seven out of 10, and 10:30 P.M. for a pain level of four out of 10). All Percocet administration doses indicated the medication was effective. There was no pain number listed for the effectiveness. There was no evidence the as needed Tylenol was administered after the resident returned from the hospital or parameters for when to administer the Tylenol versus the Percocet for pain. Review of Resident #5's administration/progress notes dated 01/27/24 to 01/31/24 revealed the nurse called Certified Nurse Practitioner (CNP) #502 to obtain order for Percocet after the resident returned from the hospital due to she was restless. On 01/27/24 at 9:52 P.M. Resident #5 received Percocet for a pain level of 3 out of 10. At 12:20 A.M. the follow up pain was four out of 10 (which was higher than prior to administration) and the nurse documented the pain medication was effective. Further review of progress note dated 01/31/24 at 3:00 A.M. revealed the resident was noted to be yelling out and upon entering the room the resident was noted to be grimacing and squeezing the STNA hands. Resident #5 was not able to voice needs due to her severe dementia. The on-call provider was called and received a one time order to administer an additional Percocet 5/235 mg. Currently, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 15 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 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 0697 Level of Harm - Minimal harm or potential for actual harm working on obtaining authorization to pull from mediwise due to the resident was out of Percocet. (There was no evidence the as needed Tylenol was utilized). There was no documented evidence on the MAR or progress note indicating non-pharmacological interventions were attempted prior to administering pain medications. Residents Affected - Few Review of the facility policy titled Pain Management Policy (dated 10/2023) revealed the purpose was to provide resident comfort with care. The procedure included: the resident would be assessed for complaints and/or signs and symptoms of pain upon admission and as indicated. Pain assessment will be completed five days after admission and quarterly. The interdisciplinary care plan team will initiate and implement a pain management plan of care. Pain interventions will be monitored for effectiveness by Nursing. The physician will be notified as indicated. Interview and review of Resident #5's MAR on 01/31/24 at 10:27 A.M., with LPN #165 and the DON confirmed there should be parameters when to administer the Tylenol versus the Percocet and they would call the provider to get clarification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 16 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of risk management report, review of hospital records, review of tracking logs, interviews, and policy review the facility failed to ensure a complete and accurate medical record. This affected one resident (#5) of three residents reviewed for falls. Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, chronic pain, polyosteoathritis, generalized anxiety, age-related osteoporosis without current pathological fracture, and repeated falls. There was no evidence the diagnoses list was updated to include the acute left hip fracture and left superior pubic ramus fracture that occurred on 01/27/24. Review of the Resident #5's risk management report (which indicated at the bottom of the report that it was not part of the medical record) dated 01/22/24 at 1:42 A.M. revealed Registered Nurse (RN) #163 was called to room by a State Tested Nurse's Aide (STNA). Resident was sitting on the floor at this time. No visible injuries were noted at this time. Resident mental status as per normal. Vitals taken at this time (97.7 Fahrenheit temperature, 18 respirations, 94% on room air, 89 heart rate, and BP 174/87). The resident was not able to give a description of the event. Assisted resident to wheelchair at this time. Moved resident to common area for observation. The resident was alert and wheelchair bound. She was oriented to person only and had no pain. Her predisposing physiological factors included confusion, gait imbalance, and impaired memory. The resident was ambulating without assistance. There was no witness. The physician was notified at 1:49 A.M. and power of attorney (POA) at 1:52 A.M. Review of Resident #5's medical record revealed on 01/23/24 at 10:39 A.M., there was a late entry authored by the Director of Nursing (DON) for 01/22/24 at 1:42 A.M. that indicated this Registered Nurse (RN) was called to the room by a State Tested Nurse's Aide (STNA). The resident was sitting on the floor at this time. No visible injuries were noted at this time. Resident mental status as per normal. Vitals taken at this time. The temperature was 97.7, respirations were 18 respirations, 94% room air, 89 heart rate, and blood pressure was 174/87. Residents are unable to give any description of the event. Assisted resident to wheelchair at this time. Moved resident to common area for observation. The resident's physician and POA was notified. A correction note was entered at 10:41 A.M. indicating RN #163 was the nurse who found the resident regarding the fall. Review of Resident #5's risk management report form dated 01/27/24 at 12:30 A.M. authored by Registered Nurse (RN) #163 revealed this RN was called to the resident room by State Tested Nurse's Aide (STNA). The resident was sitting on the floor next to the bed. Resident vitals were taken at this time (temperature was 97.7, respirations were 18, oxygen saturation was 94% room air, heart rate 89, and blood pressure was 174/87). Resident was alert to self. Pupils equal, round, reactive, light, and Accommodation (PERRLA). No visible injury was noted at this time. Resident complains of left hip pain. Resident stated that she was trying to get to the bathroom. The resident denied hitting her head. Reminded resident not to attempt to get out of bed without assistance. Pain level was a 10 and she was alert and oriented to the person only. Unable to determine the injury type but the location was in the left gluteal fold. The resident was noted to be wheelchair bound. There were no environmental factors noted. The predisposing physiological factors included the resident was confused, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 17 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incontinent, and had gait imbalance. The predisposing factors indicating the resident ambulated without assist. The on-call service was notified at 12:40 A.M. and the POA at 12:41 A.M. At the bottom of the fall investigation report form it indicated the report was privileged and confidential - not part of the medical record- do not copy. Review of Resident #5's medical record revealed no evidence of incident note or progress note regarding Resident #5's fall that occurred on 01/27/24 at 12:30 A.M. Review of Resident #5's hospital notes dated 01/27/24 revealed the x-ray showed acute moderately displaced left intertrochanteric proximal femur fracture and acute moderately displaced fracture of the left superior and inferior pubic rami. The discharge instruction was to call Physician #501 in one day for palliative care and the final diagnoses was closed traumatic displaced intertrochanteric fracture of left femur and closed fracture of multiple rami of left pubic. Interview on 01/30/24 at 10:38 A.M., with LPN #168 revealed Resident #5's fall that occurred on 01/27/24 was still being investigated and she had not interviewed any other staff at this time regarding the incidents due to the fall happened over the weekend. She was aware RN #163 had not documented the fall on 01/27/24 and had reached out to the nurse.The interview was reviewed with LPN #168 to confirm accuracy of the interview. The LPN confirmed the accuracy of the interview. Interview on 01/30/24 at 9:49 A.M., 12:03 P.M., and 1:02 P.M., with the DON confirmed she had documented the fall that occurred on 01/22/24 in Resident #5's medical record on 01/23/24 on the behalf of RN #163. The DON reported staff were instructed to type all fall information into risk management and then copy the information into the resident's medical record. RN #163 did not do that for the falls that occurred on 01/22/24 and 01/27/24. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 12:02 PM with RN#163 (and the DON) verified RN#163 was Resident #5's nurse on 01/22/24 and 01/27/24 and he did not document the falls that occurred on those dates in the medical record. RN#163 reported he thought he had documented the two falls in the medical record, and he didn't know what he had done wrong for them not to show up in the medical record. RN #163 verified he was not provided additional education regarding not documenting falls in the medical record. The interview was reviewed with RN #163 and the DON to confirm accuracy of the interview. RN #163 confirmed accuracy of the interview. Review of the facility policy titled Fall Management Policy dated 10/2023 revealed fall intervention would be posted on the [NAME] and plan of care. The nurse must document in the resident's chart in the risk management and the incident progress note. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 18 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview the facility failed to implement an effective plan/policy to prevent recurrence of a system failure that resulted in harm for Resident #5. This affected one resident (#5) and had the potential to affect all 83 residents residing in the facility. Findings included: Review of staff education dated 05/08/23 and 05/12/23 revealed when a resident has a change of condition you would need to notify the physician or the practitioner on call. Physician #501 had a communication book at each nurse station with instructions on how to contact a practitioner. If you were unable to reach a practitioner, then you have to contact the Medical Director and his phone number would be in the rolodex at each nurse's station. If you were unable to get hold of any of the above, contact the family and send them to the emergency department. Notify the nursing if the practitioner did not respond. Review of the undated communication book/form for Physician #501 (Resident #5's physician) revealed please contact the Advance Practice Registered Nurse (APRN) between 3-4:00 P.M. with all issues and as needed for emergent issues only from 6:00 A.M. to 8:00 P.M. Please see the guidelines for provider notification in the communication book. Monday through Friday 8:00 P.M. to 6:00 A.M. and Saturday, Sundays and Holidays call the office answering services (number listed) for the on-call APRN. Do not call or fax the office unless directed to do so (numbers were listed). An additional form in the communication book dated 06/2023 titled After Hours Provider Notification Protocol(8:00 P.M. to 6:00 A.M. weekday, all day on holidays and weekends) revealed the objective was to provide timely, efficient, safe, appropriate patient care by ensuring a thorough situation evaluation before contacting after-hours, on call providers. Purpose: The on-call provider's coverage is to be used for urgent issues that cannot wait until the next day a provider is in the facility or for a daytime call to the managing Advanced Practice Nurse. Information from the facility included the federal regulation regarding Notification of Changes (F517) speaks to the immediate notification which included any significant change any significant change in physical or mental status from baseline. This document was meant to use as a guide and not to replace the need for appropriate discernment to call either 911 or to contact the on-call team in the event the situation was unclear, and the patient was unstable. Included in the communication book was a checklist titled Guideline for Provider Notification dated 06/2023 revealed immediate notification would be a change in condition/mental status, fall with injury requiring further evaluation and treatment and abnormal x-ray (symptomatic and requiring treatment). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 19 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 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 0867 Level of Harm - Minimal harm or potential for actual harm Review of the facility audits and tracking log for change of condition, as part of the facility Immediate Jeopardy removal plan, dated 12/20/23 to 01/29/24 revealed the tracking form included resident name, change of condition, name of practitioner notified, POA notified, documented, and signature of DON or designee. Record review revealed no evidence a fall with injury, for Resident #5 that occurred on 12/27/23 was noted on the log. Residents Affected - Many Review of a facility Performance Improvement Project (PIP) dated 01/11/24 to 01/23/24 revealed the facility goal was to provide timely and necessary treatment to all residents and timely physician notification. The facility developed a tracking form for the floor nurses to list residents that have had a change in condition. The final measured data was completed on 01/23/24 and all physician notifications were documented to have taken place timely and no concerns with physician response time were identified. Review of facility Quality Assessment Performance Improvement (QAPI) minutes dated 01/22/24, 01/25/24, and 01/29/24 related to the F684 IJ citation revealed the QAPI team reviewed residents, notification, and the 24-hour reports and had no issues noted at this time/or met standards. Interview on 01/30/24 at 12:02 P.M., with Registered Nurse (RN) #163 and the Director of Nursing (DON) verified Resident #5 had fallen on 01/27/24 around 12:30 A.M. They indicated the resident had no visible signs of injuries, however the resident verbalized pain and had facial grimacing with movement. RN #163 attempted to call the on-call provider a few times but had to leave a message with on-call answering services. The on-call APRN did not return his call until around 6:30 A.M. The RN reported he did not know how to handle the situation because he was an emergency nurse, and this was new to him. He did not know who the medical director was until this date and he did not have his number to call him. The RN also reported he did not reach out to the DON or nursing supervisor when he was not able to reach a provider for guidance. The RN confirmed the fall was not documented in the resident's electronic medical record. The interview was reviewed with the RN and DON to confirm accuracy of the interview. The RN confirmed the accuracy of the interview. Interview on 01/30/24 at 12:03 P.M. and 1:02 P.M., with the DON revealed RN #163 should have called herself or the medical director when the on-call provider did not return his call timely. The DON reported the medical director's number was in the rolodex and staff had been educated on notification as part of the plan of correction for the surveyor that was completed on 12/27/23. The DON confirmed the change of condition log, which was part of the facility plan of correction, included falls, skin, etc. did not include Resident #5's fall because it did not trigger the 24-hour report due to the nurse not documenting the fall in the resident's medical record. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 2:07 P.M., with the DON revealed the facility uses an on-call provider system after hours. Medical Director #500 and Physician #501 were a part of the on-call system. As part of the facility plan of correction for the Immediate Jeopardy that the facility received on 12/27/23 if there was urgent issue the nurse was to ensure the provider would respond in 20 minutes and if was a non-urgent issue the staff were to keep trying to call. The resident (Resident #5) who had a suspected fracture and needed an x-ray would have been an urgent issue. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 3:11 P.M. with the Administrator revealed the on-call system was a group of providers who cover for one another. Some of the providers did not provide services to the residents except for answering the on-calls that come in. Sometimes the providers would answer calls and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 20 of 21 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 366093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Health Care Center Inc 1525 Crater Avenue Dover, OH 44622 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sometimes it would go to an answering service, and the answering service would contact the one call provider. The facility expected the provider to call back within 20 minutes if there was an adverse effect. The Administrator verified Resident #5's fall with possible fracture suspected would be an example of an adverse event. The nurse should notify the family or send the resident to the emergency room if an adverse event occurs, and the provider doesn't return a call. The interview was reviewed with the Administrator to confirm accuracy of the interview. The Administrator confirmed the accuracy of the interview. Review of the facility undated policy titled QAPI Policy and Procedure revealed the PIPs data source included survey findings. The committee would consider and prioritize both external and internal elements affecting the long-term care industry and facility when selecting priorities of focus for the coming year. Once the PIP had been approved, the QAPI Committee would establish a QAPI charter, timeline, and to allocate staff and resources prior to the launch of the PIP. The PIP team members would be selected based on scope of the work, considering such factors as time commitment and expertise. Whenever possible, the facility should consider a resident/family advisor to be appointed to the team. Meeting minutes would be recorded and shared with the QAPI Steering Committee, Executive Leadership, and staff. The facility would use data from every QAPI Steering Committee to ensure performance measures are meeting QAPI Goals. PSDA cycles would be utilized to improve existing processes. Data specific to the PDSA intervention would be collected and monitored to the end of each cycle. Since PDSA cycles were dynamic and current, data collected during these intervention periods would be analyzed on a frequency designated by the PIP team and/or QAPI Committee that would be useful for making mid-cycle adjustments. The PDSA cycle outcomes would be reported to the QAPI Committee at least quarterly; however, more frequent monitoring may be required for rapid cycle PDSA cycles of change to capture the impact of the change once the intervention was spread across the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 21 of 21