Park View Care Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

approximately two inches in length on the exterior front of the toilet, and a darker brown speckled substance on the back wall of the interior bowl, approximately two inches in diameter. LPN #201 confirmed

these observations. LPN #201 stated residents complained about the lack of cleanliness, particularly in the bathrooms.Observation on 12/23/25 at 2:44 P.M., and concurrent interview with Housekeeping Manager (HM) #400, revealed Resident #54's toilet had a brown substance on the front exterior of the bowl, and a brown speckled substance on the back of the interior bowl. HM #400 confirmed these observations. HM #400 confirmed Housekeeper #401 was assigned to clean and restock Resident #54's room, including the bathroom. Interview on 12/23/25 at 3:23 P.M. with the Director of Nursing (DON) revealed she heard complaints about unclean toilets. The DON stated when she reported her concerns to the housekeeping department, and the concerns were always addressed. The DON confirmed Resident #54 used their restroom.3. Review of the medical record for Resident #56 revealed an admission date of 11/18/24 with diagnoses including schizoaffective disorder, depression, and auditory hallucinations. The quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #56 had intact cognition. Interview

on 12/23/25 at 10:05 A.M. with Certified Nursing Assistant (CNA) #102 confirmed some residents complained about bathrooms and toilets not being cleaned.Interview on 12/23/25 at 11:21 A.M. with Infection Preventionist (IP) #301 revealed staff and residents have reported concerns to her regarding cleanliness and infection control. IP #301 stated these concerns have been reported since approximately early November 2025. IP #301 stated she reported the concerns to the Administrator.Interview on 12/23/25 at 11:32 A.M. with Housekeeping Manager (HM) #400 revealed she had received no concerns regarding

the cleanliness of resident rooms.Interview on 12/23/25 at 12:01 P.M. with CNA #103 revealed she had concerns regarding the lack of housekeeping in resident rooms.Interview on 12/23/25 at 12:29 P.M. with Housekeeper #401 revealed she still needed to clean the resident rooms on the memory care unit before

the end of her shift at 2:00 P.M. Housekeeper #401's assignment included Resident #56's room.Interview

on 12/23/25 at 2:42 P.M. with Resident #56 revealed she had no toilet paper in her bathroom.Observation

on 12/23/25 at 2:43 P.M., and concurrent interview with HM #400, revealed Resident #56's bathroom had no toilet paper. HM #400 confirmed Housekeeper #401 was assigned to clean and restock Resident #56's rooms, including the bathroom. Interview on 12/23/25 at 2:54 P.M. with HM #400 confirmed Resident #56's bathroom should have had an adequate supply of toilet paper during the observation on 12/23/25 at 2:42 P.M. if her toilet paper had been restocked by Housekeeper #401.Interview on 12/23/25 at 3:23 P.M. with

the Director of Nursing (DON) revealed she heard complaints about unclean toilets. The DON stated when

she reported her concerns to the housekeeping department, and the concerns were always addressed. The DON confirmed Resident #56 used their restroom.Review of the Resident Council meeting minutes dated 10/28/25 revealed old business included housekeeping cleaning floors. Current business included residents questioning what tasks housekeeping was expected to perform. Review of a response form dated 10/30/25, completed by HM #400, revealed daily tasks included cleaning the bathroom. Review of the Resident Council meeting minutes dated 11/18/25 revealed specific residents complained their floors were not getting clean.Review of the housekeeping daily checklist revealed duties included checking and refilling supplies and cleaning the commode and base. This deficiency represents non-compliance investigated under Complaint Number 2690900.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park View Care Center

328 West Vine Street Edgerton, OH 43517

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, staff interview, review of Resident Council meeting minutes, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) during a COVID-19 outbreak. This had the potential to affect all residents in the facility except 10 residents (#11, #13, #21, #25, #31, #58, #65, #68, #71, and #72) who were identified with a current COVID-19 infection. The facility census was 62.Findings include:Interview on 12/23/25 at 8:42 A.M. with Infection Preventionist (IP) #301 revealed the facility was in COVID-19 outbreak and identified ten residents with COVID-19 (#11, #13, #21, #25, #31, #58, #65, #68, #71, and #72). IP #301 reported no residents on the Memory Care Unit were diagnosed with COVID-19.

Observation on 12/23/25 at 12:10 P.M. revealed signage posted outside Resident #11's door indicating Resident #11 was in droplet precautions for COVID-19. Housekeeping Manager (HM) #400 was in Resident #11's bathroom cleaning her toilet. HM #400 was not wearing a disposable gown or eye protection.

Interview on 12/23/25 at 12:15 P.M. with HM #400 confirmed Resident #11 was in COVID-19 isolation and staff should wear PPE, including a gown, N95 mask, eye protection, and gloves while in the room. HM #400 confirmed she went into Resident #11's room to clean her toilet bowl and only wore the N95 mask she had on. Further observation revealed HM #400 wore a distinct striped mask. There were no striped masks observed in the PPE cart outside Resident #13's room.Further observation on 12/23/25 at 12:20 P.M. revealed signage posted outside the room shared by Resident #12 and Resident #13 indicating the residents were in droplet precautions for COVID-19. HM #400 donned a gown and gloves before entering

the room shared by Resident #12 and Resident #13 and did not change her N95 mask. HM #400 did not put on eye protection before she walked past both residents in the room and entered the bathroom.Interview on 12/23/25 at 11:32 A.M. with HM #400 revealed she worked on the floor as a housekeeper and had completed all room cleanings for the day, including rooms for Resident #11, Resident #13, Resident #21, Resident #25, and Resident #31, who were identified to be in COVID-19 precautions.Interview on 12/23/25 at 12:29 P.M. with HM #400 and Housekeeper #401 stated they both do not change their N95 masks throughout the day. HM #400 and Housekeeper #401 stated they were unaware they were expected to discard their N95 mask before exiting a resident's room who was in COVID-19 droplet precautions. HM #400 confirmed she cleaned all 24 rooms on her assignment, including five rooms identified to be in COVID-19 precautions without changing her N95 mask.Follow-up interview on 12/23/25 at 3:35 P.M. with IP #301 revealed all staff should be wearing gown, gloves, N95 masks, and eye protection before entering rooms in COVID-19 precautions. IP #301 confirmed N95 masks should be changed upon exiting COVID-19 rooms. Additionally, IP #301 confirmed the facility had a COVID-19 outbreak during November 2025 and explained it was 29 days between the end of the previous outbreak and the current outbreak.Review of the Resident Council meeting minutes dated 11/18/25 revealed housekeeping staff were not using PPE in COVID-19 rooms before going into other rooms.Review of the facility's undated document Special Respiratory Precautions revealed staff were expected to wear goggles or face shield, an N95 mask, a gown, and a pair of clean gloves before entering a room in COVID-19 precautions.Review of CDC guidance titled Transmission-Based Precautions dated 04/03/24 and found at https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html revealed droplet precautions included everyone must make sure their eyes, nose, and mouth are fully covered before room entry and make sure to remove face protection before room exit.This was an incidental finding during the complaint survey completed 12/24/25.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet