Health inspection·June 22, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's Self-Reported Incidents (SRI), and policy review the facility failed to investigate and report an injury of unknown origin to the state agency. This affected one resident (#5) out of one resident reviewed for abuse. The facility census was 39. Findings include: Observation on 06/20/23 at 11:53 A.M. revealed Resident #5 was noted to have a quarter size purple bruise with slight edema directly under her left eye. Interview at this time with Resident #5 revealed she was unsure of what happened to her eye. Review of the facility's SRIs revealed the last reported SRI was reported to the state agency on 03/27/18. Review of Resident #5's medical record revealed an admission date of 12/08/22. Diagnoses included dementia with behavioral disturbance, age related cognitive decline, hallucinations, anxiety disorder, and muscle weakness. A complete review of the medical record revealed a skin assessment of the residents bruising was never documented into the medical record. Review of Resident #5's Quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was moderately cognitively impaired. Review of Resident #5's nursing progress note dated 06/06/23 at 5:50 P.M. Licensed Practical Nurse (LPN) #247 charted, Resident #5 was sitting at dining room table with another resident and was asked how she got the black eye. Resident #5 responded she poked herself with a pencil. Later LPN #247 asked the resident what happened, and she responded she poked her eye with a razor blade. The resident also had a bruise on the top of her shoulder which was yellow in color, and her left forearm black in color. Review of Resident #5's Nursing progress note, entered as a late entry, the note was created by the Director of Nursing (DON) on 06/20/23 at 11:28 A.M. and noted to be effective on 06/07/23 at 11:26 A.M. stated this was the investigation of bruise to the residents left eye. The note continued to state a nurse observed a bruise under Resident #5's left eye and a fading bruise on her shoulder. The resident was alert and oriented to person only and was unable to recall any incidents that resulted in the injuries. She was overheard by staff one day telling another staff member that she poked (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: 366449 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 366449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Hc NP LLC 1019 Oldtown Valley Road SE New Philadelphia, OH 44663 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)