Inspection·April 4, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #57 had a Pre-admission Assessment Screening (PASRR) in place after the expiration of a Hospital Exemption. This affected one (Resident #57) of one resident reviewed for PASRR. The facility census was 74. Residents Affected - Few Findings included: Record review revealed Resident #57 admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, dementia with psychotic disturbance, congestive heart failure, anxiety disorder, delusional disorders, hallucinations, neurocognitive disorder with lewy bodies, and major depressive disorder. Review of a significant change minimum data set (MDS) dated [DATE] revealed Resident #57 did not have a level two PASRR (ensures the appropriate placement of persons with mental illness or intellectual disability and determines if an individual requires specialized rehabilitative services). Review of a Hospital Exemption dated 02/27/23 revealed an expiration date of 03/29/23. There was no other evidence of a PASRR being completed prior to admission or the expiration of the 30 Day Hospital Exemption. Interview on 04/02/24 at 1:11 PM with Social Services Director (SSD) revealed new PASRR's are done when residents come from the hospital within the first 30 days. SSD stated she did not see where a PASRR was completed for Resident #57, but did see a hospital exemption was in place. Review of a PASRR policy dated 03/24/20 revealed PASRRs should be completed by the designee for all residents prior to admission to the facility, with the exception of residents with a hospital exemption. In this situation, the PASRR will be completed by the 29 th day after admission, and all PASRR will be reviewed and signed by the Director of Nursing. Any resident who requires a level II screen will be considered part of the PASRR population, a new resident review will be completed following a significant change of condition for the resident. Any resident who has a clean level I PASRR will be considered part of the non PAS population. A new resident review will be completed following admission to psychiatric hospital or upon the addition of a new psychiatric diagnosis and/or medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 2 of 4 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 04/04/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and policy review, the facility failed to properly store food in the refrigerators. This had the potential to affect 73 of 74 residents in the facility who receive meals from the kitchen. The facility identified Resident #1 to receive alternate nutrition. The facility census was 74. Findings included: Observation on 04/01/24 at 9:39 A.M. of the meat refrigerator revealed a large pan of chicken on the bottom shelf which had thawed and leaked onto the bottom of the refrigerator, and rusty shelving. Observation on 04/01/24 at 9:43 A.M. revealed one gallon of milk expired on 03/28/24 and a gallon Ziploc bag of peanut butter and jelly sandwiches were not dated. Interview on 04/01/24 at 9:49 A.M. with Dietary Manager #102 confirmed findings. Review of a policy titled Date Marking and Disposal of Ready to Eat Potentially Hazardous Foods revised on 04/16/23 revealed dated marking is a tool to help ensure food safety and helps staff to know how old the food item is. Refrigerated, ready to eat, potentially hazardous food prepared and held for more than 24 hours must be marked with the date of preparation. A food packaged by a food processing plant must be consumed or discarded within seven calendar days after the original package is opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 3 of 4 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 04/04/2024 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)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, policy review and staff interview the facility to ensure residents had an appropriate indication for antibiotic use. This affected one (Resident #54) of five residents reviewed for medication use. The facility census was 74. Residents Affected - Few Findings include: Review of Resident #54's medical record revealed an admission date of 11/04/23 with diagnoses that included congestive heart failure, cerebrovascular accident and dementia. Further review of Resident #54's medical record including advanced practitioner's orders revealed on 03/21/24 the resident was prescribed amoxicillin-potassium clavulanate (antibiotic) 875 milligrams (mg) every 12 hours for seven days for aspiration pneumonia. On 03/23/24 the medication was discontinued due to a chest x-ray completed that was negative for pneumonia. Review of Resident #54's Medication Administration Record (MAR) revealed the resident was administered the medication as ordered from 03/21/24 evening to 03/23/24 morning for a total of four doses administered. An antibiotic assessment completed on 03/23/24 indicated the chest x-ray was negative and therefore did not meet criteria for antibiotic use. Review of the chest x-ray completed on 03/23/24 revealed no evidence of pneumonia. Interview with Registered Nurse (RN) #101 on 04/04/24 at 9:05 A.M. verified an antibiotic was started for Resident #54 prior to obtaining a chest x-ray and was then discontinued after a negative chest x-ray. Resident #54 also received four doses of antibiotic without an appropriate indication for use. Review of the facility policy titled Antibiotic Surveillance Policy and Procedure with a review date of October 2023 revealed the nurse is to initiate a McGeer's assessment when a resident starts to show signs and symptoms of an infection. If the resident meets criteria, then the physician is to be notified. If an antibiotic is ordered an assessment has not been completed, the nurse must notify the practitioner for the reasoning behind the antibiotic usage. A McGeer's assessment should then be initiated and if criteria are not met than the practitioner must be notified that criteria is not met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366093 If continuation sheet Page 4 of 4