Inspection·February 28, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure proper infection control practices and procedures were in place to prevent the spread of Respiratory Syncytial Virus (RSV). This had the potential to affect all 70 residents who resided in the facility. Residents Affected - Many Findings Include: Resident #76 was admitted to the facility on [DATE] and expired [DATE]. Diagnoses included diabetes mellitus, persistent mood affect disorder, major depressive disorder, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #76 had severely impaired cognition and required substantial assistance for walking and had behaviors of wandering one to three days during the seven-day look back period. Review of the order note dated [DATE] at 4:57 P.M. revealed that the son of Resident #76 was notified of Resident #76 tested positive for RSV and would be in isolation for at least eight days. Interview on [DATE] at 11:56 A.M. with the Director of Nursing (DON) revealed Resident #76 would sit in her wheelchair in the common area because she was a fall risk, so we put her where we could watch her. We tried to keep Resident #76's mask on, but she would take it off. Interview on [DATE] at 2:23 P.M. with Activity Director #105 revealed that Resident #76 was not isolated because the resident had behaviors of yelling, she would want to get up and look for her family. Resident #76 would wander around in her wheelchair. Interview on [DATE] at 2:33 P.M. with State Tested Nursing Assistant (STNA) #106 revealed Resident #76 had RSV and should have been quarantined. She was out in the common area because she was a fall risk. STNA #106 stated that Resident #76 had to be checked on every two hours. Interview on [DATE] at 2:54 P.M. with the Administrator revealed Resident #76 was out in the common area because she was a fall risk. Resident #76 would not keep a mask on. He did not call the local or state health department for guidance, and no meeting was held with the medical director. Review of the facility policy titled, RSV Infection Control Prevention Measures, dated 01/2023, revealed that residents who test positive for RSV will immediately be put in contact plus droplet precautions. Residents that are at high fall risk will be put in isolation and every effort will be made to keep the resident safe. If the resident must be out of their room, staff will make every effort to put the resident in an area away from other residents, encourage the resident to wear a mask, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366093 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 02/28/2024 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)