Inspection·November 14, 2019

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete quarterly assessments for residents in a timely manner. This affected two (Residents #2 and #8) of 24 residents reviewed for assessments. The facility census was 54. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 09/19/17 with diagnosis of cerebral infarction (stroke). Review of the comprehensive Minimum Data Set (MDS) assessment revealed it was completed on 07/08/19. Review of the quarterly MDS for Resident #2 had been started with an assessment reference date of 10/08/19, however the MDS had not been completed, or submitted. 2. Review of the medical record for Resident #8 revealed an admission date of 08/02/18 with a diagnosis of hemiplegia following cerebral infarction. Review of the comprehensive MDS assessment revealed it was completed on 07/24/19. Review of the quarterly MDS assessment revealed it had been started on 10/24/19, however had not been completed or submitted. Interview on 11/13/19 at 2:38 P.M. with RN #210 confirmed Resident #2 and #8's quarterly MDS assessment had not been completed or submitted. Review of the RAI Manual updated 10/01/19 Chapter 2 page 2-17 revealed a quarterly assessment must be completed within the following timeframe: the assessment reference date of the previous assessment of any type plus 92 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 2 of 6 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 365363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Nursing and Rehabilitation Center 908 Symmes Road Fairfield, OH 45014 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident with a gastrostomy tube (g-tube) had orders and treatments in place to potentially prevent complications related to the g-tube. This affected one (Resident #12) of one reviewed for tube feeding. The facility census was 54. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with a diagnosis of quadriplegia. Review of the care plan for Resident #12 dated 08/20/12 revealed the resident had a g-tube used for medication administration. Interventions included to flush the g-tube per physician's order, dressing change to the g-tube per physician's order, and to check placement of the g-tube per physician's order. Review of Minimum Data Set (MDS) assessment for Resident #12 dated 08/13/19 revealed resident was cognitively intact, was totally dependent on staff with activities of daily living, and had a g-tube. Review of November 2019 physician orders for Resident #12 revealed orders for a regular diet and for the following medications to be administered per g-tube; atorvastatin, Sinemet, Colace, ferrous sulfate, lactulose, midodrine, senna tab. There were no orders for the g-tube to be flushed, when the g-tube should be changed, or for inspecting or caring for the g-tube insertion site. Review of the November 2019 Treatment Administration Record (TAR) and Medication Administration Record (MAR) for Resident #12 revealed there were no treatments or flushes signed off related to the resident's g-tube. Interview on 11/14/19 at 2:00 P.M. with Registered Nurse (RN) #40 confirmed Resident #12 consumed a regular diet, however the g-tube was used for medication administration. RN #40 further confirmed there were no physician's orders regarding caring for the resident's g-tube. Review of facility policy dated 07/18 titled Enteral Nutrition revealed residents with feeding tubes will receive care consistent with standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 3 of 6 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 365363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Nursing and Rehabilitation Center 908 Symmes Road Fairfield, OH 45014 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an as needed anti-anxiety medication order included a duration for the medication. This affected one (Resident #2) of six residents reviewed for unnecessary medications. The facility census was 54. Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/19/17 with a diagnosis of cerebral infarction (stroke). Review of Resident #2's physician order dated 06/14/19 revealed an order for Ativan (anti-anxiety) every four hours, as needed for shortness of breath and agitation. There was no stop date for the medication. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively impaired. Interview on 11/13/19 at 4:37 P.M. with Registered Nurse (RN) #270 confirmed the as needed Ativan ordered for Resident #2 on 06/14/19 did not have a stop date or duration for the order. Interview with Physician #55 on 11/14/19 at 2:58 P.M. confirmed when he wrote the order for Ativan every four hours for Resident #2 he did not include a stop date. Physician #55 further confirmed the pharmacy called him and asked for clarification regarding the duration of the order, however he did not communicate the intended stop date to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 4 of 6 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 365363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Nursing and Rehabilitation Center 908 Symmes Road Fairfield, OH 45014 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, the facility failed to arrange for timely dental services for one resident (#22) of two reviewed for dental care. The facility census was 54. Residents Affected - Few Findings include: Medical record review revealed Resident # 22 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, schizoaffective disorder, and history of respiratory failure. Review of Resident #22's nurse's note dated 08/30/19 at 3:47 P.M., revealed Resident #22 had been out to a Dental Clinic and returned with a molar removed. Resident #22 was scheduled to return to the clinic on 09/25/19 at 8:45 A.M., for a consultation. Review of Resident #22's nurse's note dated 09/25/19 revealed Resident #22 returned from the Dental Clinic with a plan to be scheduled for a surgery procedure. The Dental Clinic note revealed the clinic would call the facility no later than 10/02/19 to schedule the appointment. However, if they had not, the facilty should follow up with them to schedule the surgery. The name and number was left for the facility as to who to contact. The treatment plan from the Dental Clinic revealed Resident #22 had an extra bone in her bottom jaw, as well as extra tissue on the top jaw that needed removed, along with extractions. Review of nurse's note dated 10/03/19 at 4:00 P.M., revealed the Director of Nursing (DON) documented she had called the Dental Clinic to see if an appointment had been set up for Resident #22. The DON left a message with the answering service regarding the appointment. There was no further evidence there was any follow made to ensure the surgery was scheduled in a timely manner. Interview on 11/12/19 at 11:50 A.M., with Resident #22 revealed she had been to the Dental Clinic in September 2019 and was told she needed to have oral surgery to remove a bone in her jaw and to extract abscessed teeth. She revealed she had been asking the nursing staff when her appointment was and was told they did not know. She revealed she was having a problem with eating and it hurt for her to chew, so she was going to tell the Dietician to send her meat that was ground up. Interview on 11/12/19 at 3:47 P.M.,with the DON confirmed she had made a phone call to the Dental Clinic on 10/03/19 and left a message with the answering service concerning the need for an appointment for the oral surgery for Resident #22. The DON revealed she had not heard back from the Dental Clinic, nor had there been anymore attempts to reach the clinic in order to schedule the surgery. On 11/14/19 at 9:45 A.M., an interview with Social Worker (SW) #790 revealed she made arrangements for dental services within the facility, and the nurses were to arrange for dental services outside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 5 of 6 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 365363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Nursing and Rehabilitation Center 908 Symmes Road Fairfield, OH 45014 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, staff interview, and review of refrigerator rules, the facility failed to ensure food being held in a snack refrigerator used for residents were not past its specified expiration date. This had the potential to affect 49 of 54 residents who consumed food from the refrigerator. The facility identified five residents (#25, #10, #21, #13, and #15) who received nothing by mouth. Findings include: Review of the posting on the resident refrigerator in the Activity Room titled, Resident Refrigerator Rules revealed the refrigerator was for resident use only, staff items should not be stored inside; any items put in the refrigerator need to be labeled and dated with the resident's name and date; any food/drink item that is not labeled (name and date) or is more than 3 days old will be thrown away immediately. On 11/13/19 at 11:10 A.M. observation the resident snack refrigerator in the Activity Room with the Dietary Manager (#45) revealed the following spoiled and/or outdated food items: a) There was a 1/2 gallon plastic carton of chocolate milk which was visibly curdled and spoiled. The chocolate milk was dated 08/25/19. b) There was a jar of pizza sauce that had been mostly used with a large chunk of greenish mold growing on the surface of the pizza sauce. The jar was not labeled as to when it had been opened. c) There was a 1/2 gallon carton of almond milk with a use by date of 08/19/19. d) There were 2 small containers of canned refrigerator biscuits with a use of date of 10/06/19. e) There was a 1/2 gallon plastic carton of orange juice with a use by date of 10/24/19. f) There was a 2 1/2 quart glass bowl with a lid containing what appeared to be a cooked ground beef and tomato mixture. The bowl was half full, and was not labeled or dated. The exterior of the bowl and lid were soiled with dried on food. g) There was another large glass bowl with a lid containing a coating of what appeared to be egg salad throughout the bowl. The bowl was not labeled or dated. h) There was a white plastic bag, which contained a Styrofoam take-out container of food. There was no resident name on the bag or on the Styrofoam container, and there was not date as to when the item was placed in the refrigerator. i) The bottom interior of the refrigerator was soiled with sticky food spills and debris. DM #45 confirmed the observations above at the time of the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 6 of 6