Inspection·March 6, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and medical record review the facility failed to ensure Resident #32's physician orders related to wrapping his bilateral legs and feet were followed. This affected one (Resident #32) of one residents reviewed for edema. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #32 revealed an admission date of 11/09/24. Diagnoses include congestive heart failure (CHF), unspecified atrial fibrillation, and fluid overload. Review of Resident #32's Minimum Data Set Assessment revealed the resident had intact cognition. Review of Resident #32's care plan dated 02/19/25 revealed the resident has a fluid overload or potential fluid volume overload related to CHF and edema. Interventions included ace wraps to bilateral lover extremities to be put on in the morning and off at night. Review of the nursing progress note dated 02/18/25 Registered Nurse #150 documented the wound Certified Nurse Practitioner noted two plus edema to (the resident's) bilateral lower extremities. A new order for ace wraps to the bilateral lower extremities to be put on in the A.M. and off at night. Review of Resident #32's current physician orders revealed an order dated 02/18/25 to apply ace wraps to bilateral lower extremities on in the A.M., take off in the P.M., and wrap from toes to knees. The order had instructions to complete this every day shift. Observation on 03/03/25 at 10:51 A.M. revealed Resident #32 was seated in his wheelchair. His feet were resting on the floor and his legs and feet were noted to be moderately swollen. Observation on 03/04/25 at 2:11 P.M. revealed Resident #32 was seated in his wheelchair with his feet resting on the floor. His legs and feet were noted to be moderately swollen. Interview on 03/04/25 at 2:11 P.M. with Family Member #151 reported the facility frequently forgot to wrap the resident's legs and feet. Family Member #151 reported that at the resident's most recent care conference, the facility stated if he is not in bed, his legs and feet should be wrapped. She stated that lately the facility had not been following this order. Review of Resident #32's March 2025 Treat Administration Record revealed Registered Nurse (RN) #138 signed off that Resident #32's ace wraps were in place on 03/03/25 and 03/04/25. Interview on 03/04/25 at 2:13 P.M. RN #138 verified she signed off that Resident #138 ace wraps were applied to his bilateral lower extremities but confirmed they were not in place on 03/03/25 or 03/04/25. She stated she would have one of the Certified Nursing Assistants apply them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366449 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 366449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and policy review the facility failed to ensure Resident #3 received adequate monitoring for side effects related to the use of anticoagulant medication. This affected one (Resident #3) of five residents reviewed for medication monitoring. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/06/2024. Diagnoses included combined systolic and diastolic heart failure, paroxysmal atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure, and intracardiac thrombosis. Review of Resident #3's physician orders revealed orders for apixaban (anticoagulant or blood thinning medication) 5 milligrams (mg) by mouth two times a day for atrial fibrillation, Aspirin (blood thinning medication) 81 mg by mouth one time a day related to atrial fibrillation, and clopidogrel disulfate (antiplatelet) 75 mg by mouth one time a day for atrial fibrillation. Review of Resident #3's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had intact cognition and received anticoagulant medication (a medication that slows down or prevents blood clotting). Review of Resident #3's 01/20/25 plan of care revealed the resident is on anticoagulant therapy related to atrial fibrillation. Interventions included to administer anticoagulant (medication) per physician order, daily skin inspection and report abnormalities to the nurse, and observe/assess/document/report as needed adverse reactions of anticoagulant therapy including blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath. Observation on 03/03/25 at 9:11 A.M. revealed Resident #3 had notable bruising on her left hand spreading across three fingers. A moderate size bruise to her right hand spreading across two fingers and another bruise proximal to her thumb. An interview with Resident #3 at the time of the observation revealed the resident reported that she was on blood thinning medication which caused her to bruise easily. She stated that she probably hit her hands against something causing the bruising. Review of Resident #3's nursing progress notes from 02/15/25 through 03/05/25 revealed no evidence of bruising to Resident #3's bilateral hands or fingers was noted. Interview on 03/05/25 at 10:01 A.M. with the Director of Nursing (DON) revealed that if a resident's care plan stated to monitor a resident's skin daily and any issues, including bruising, should be documented in the nursing progress notes. Interview on 03/05/25 at 10:22 A.M. with the DON verified the facility did not complete daily anticoagulant monitoring or assess and monitor the bruising to Resident #3's bilateral hands and fingers. Review of the facility policy, Anticoagulant Policy and Procedure dated 10/2024 revealed residents on anticoagulant therapy will be monitored for signs and symptoms of bleeding and or new or excessive bruising. A physician or Certified Nurse Practitioner will be notified of any signs and symptoms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366449 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 366449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 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)

F 0757 of bleeding and or new excessive bruising. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366449 If continuation sheet Page 4 of 4