Inspection·June 27, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to complete a significant change pre-admission screening and resident review (PASARR) after identifying new mental health diagnoses. This affected one (Resident #33) of three residents reviewed for PASARR program. The facility census was 73. Findings include: Review of medical record revealed Resident #33 was admitted on [DATE] with diagnoses that included hemiplegia/hemiparesis following cerebral infarction, unspecified seizures, and hypertensive heart disease without heart failure, and major depressive disorder. Additional diagnoses identified on 04/13/19 included unspecified anxiety and unspecified psychosis. Review of the most recent quarterly Minimum Data Set (MDS) assessment completed on 04/13/22 revealed Resident #33 was severely cognitively impaired, had physical and verbal behaviors, did not wander, and occasionally rejected care. Resident #33 was a two-person assist and required extensive assistance with bed mobility, total assistance with transfers, locomotion, dressing, toileting, and personal hygiene, and supervision with eating. Review of PASARR outcome letter dated 07/27/18 revealed Resident #33 had no indications of Serious Mental Illness (SMI) and did not require level II services. During an interview on 06/23/22 at 10:18 A.M., the Director of Nursing (DON) verified Resident #33 had not had an updated PASSAR since admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 2 of 11 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 06/27/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #07 revealed admission date of 01/22/20 and readmitted on [DATE]. Diagnoses included, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene, glaucoma secondary to other eye disorders, bilateral, chronic pain syndrome, aphasia, and dysphagia. Review of the annual MDS dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance of two plus persons physical assistance for bed mobility, and total dependence for transfers and toilet use. Resident #07 required extensive one person assistance for dressing and personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands. The resident was independent with setup help only for eating. The resident had functional limitation in range of motion with impairment on one side of upper and lower extremity. The resident had no guardian or legally authorized representative. Review of Interdisciplinary Care Plan Conference Summary revealed 08/31/21 as the most recent documented Care Conference. The medical record contained no further evidence regarding care conferences offered, completed, or refused. Interview on 06/23/22 at 10:20 A.M. the DON verified she could provide no additional evidence of quarterly care conferences for Resident #07. 3. Review of medical record for Resident #16 revealed admission date of 11/9/19 with no cognitive deficits. The resident was admitted with diagnoses including chronic venous hypertension, heart disease, and type two diabetic . Review of the nurses and social services progress notes from 04/21/21 to 06/20/22 revealed no indication the resident was invited for a care conference prior to 06/21/22. During an interview on 06/23/22 at 8:58 A.M. the DON stated prior to January 2022 care conferences were documented on paper and kept on file with Social Services. The DON verified the facility had no evidence of Resident #16 being invited to a Care Conference or evidence a Care Plan conference was held for Resident #16. On 06/23/22 at 10:20 A.M. interview with Resident #16 confirmed he had not been invited to a care plan conference since he was admitted . Based on interview, record review, and policy review, the facility failed to complete quarterly care conferences. This affected four residents (#07, #16, #43, and #57) out of 24 residents sampled for care conferences. The facility census was 73. Findings include: 1. Resident #57 admitted to the facility on [DATE], was readmitted [DATE], with diagnoses that included but were not limited to dependence on respirator, type II diabetes, chronic diastolic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 3 of 11 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 06/27/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some congestive heart failure, morbid obesity, unspecified anxiety disorder, major depressive disorder - single episode, and chronic respiratory failure with hypoxia. Review of the most recent annual Minimum Dat Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact, had no behaviors, did not wander, and frequently refused care. Resident #57 was a two-person assist and required extensive assistance with bed mobility, dressing, and personal hygiene, total assistance with transfers, toileting, and bathing, and was independent with eating and locomotion. Review of the medical record revealed Resident #57's sister was notified via letter on 04/26/22 of care conference scheduled on 05/17/22. On 05/05/22, Resident#57 refused care conference and stated he had no concerns with care. The medical record contained no further evidence regarding care conferences offered, completed, or refused. During an interview on 06/23/22 at 8:58 A.M. the Director of Nursing (DON) stated prior to January 2022 care conferences were documented on paper and kept on file with Social Services. The DON verified the facility had no evidence of quarterly care conferences conducted prior to January 2022 for Resident #57. 4. Review of the medical record for Resident #43 revealed an admission date of 04/06/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, history of Covid, gastroesophageal reflux disease, dysphagia, cognitive communication deficit, bipolar disorder, and anxiety disorder. Review of the 5-day Medicare MDS assessment for Resident #43 dated 04/12/22 revealed the resident was cognitively intact. The resident had no hallucinations, delusions, or rejection of care noted in the assessment. Resident #43 required total dependence from staff with toileting, eating, locomotion on/off unit. The resident required extensive assistance from staff for bed mobility, transfers, dressing, and hygiene. Review of the medical record for Resident #43 revealed no documentation of any care conferences held by the facility. During an interview on 06/23/22 at 8:58 A.M. the DON stated prior to January 2022 care conferences were documented on paper and kept on file with Social Services. The DON verified the facility had no evidence of care conferences for Resident #43. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 4 of 11 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 06/27/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, observations, and staff interview the facility failed to obtain treatment orders for Resident #02 and failed to continue medication orders for Resident #56. This affected two residents (#02 and #56) out of three residents reviewed for continuity of care. The facility census was 73. Residents Affected - Few Findings included: 1. Review of medical record for Resident #02 revealed readmission date of 5/24/22 with a no cognitive deficits. The resident was admitted with diagnoses of chronic small [NAME] obstruction status post decompressive gastrostomy continue with decompression to gravity, rectal cancer, and type two diabetic. Review of Resident #02's care plan last updated on 11/22/21 revealed no instructions of taking care of the decompressive gastrostomy. Review of Resident #02's physician orders last updated on 5/24/22 revealed no care instructions for the decompressive gastrostomy. Review of the physician progress notes for 05/04/22, 05/07/22, 05/27/22, and 05/27/22 revealed no care instructions for the decompressive gastrostomy. Review of Resident #02's medication and treatment administration records do not include care instructions for the decompressive gastrostomy. On 06/22/22 at 9:30 A.M. observation and interview with Resident #02 revealed a foul smell in his room. Observation of a canister sitting on a side table revealed a dark brown , black substance. The canister was filled to the top. Interview at 9:35 A.M. with Registered Nurse (RN) #108 revealed she did not know what the smell was and it is not unusual for Resident #02's room to smell like it does. Interview at 9:45 A.M. with the Assistant Director of Nursing (ADON) revealed the smell is from the decompressive gastrostomy. Interview on 6/23/22 at 12:55 P.M. with Medical Doctor (MD) #500 regarding Resident #02 revealed he was aware of the decompressive gastrostomy continued with decompression to gravity. He revealed the care instructions for the decompressive gastrostomy was detailed in the hospital discharge paper work. Interview on 06/23/22 at 1:15 P.M. with DON confirmed Resident #02's physician orders or care plan does not contain the care instructions for the decompressive gastrostomy. Review of the Physician - Medication and Treatment Orders Policy and Procedures (8/18) revealed treatment orders will be documented in the Physician's orders and on the Treatment Administration Record. 2. Review of the medical record for Resident #56 revealed an original admission date of 01/12/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 5 of 11 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 06/27/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The resident had hospital stays from 01/13/22-01/20/22, 01/22/22-02/02/22, 02/11/22-02/15/22, and 06/07/22-06/09/22. Diagnoses included dependence on respirator, viral pneumonia, type 2 diabetes mellitus, muscle weakness, urinary tract infection, and schizoaffective disorder. Review of the quarterly minimum data set (MDS) assessment for Resident #56 dated 06/10/22 revealed the resident had an intact cognition. No hallucinations, delusions, or rejections of care were noted by the assessment. Resident #56 required total dependence from at least one staff member for hygiene, toileting, dressing, locomotion on/off unit, and transfers. The resident required extensive assistance from staff for bed mobility and supervision with eating. Review of the hospital paperwork for Resident #56 dated 06/09/22 revealed an order to continue Eliquis (Blood thinner) 5 milligram (mg) tablet twice daily via g-tube or PEG tube. Review of the follow up progress note for Resident #56 written on 06/10/22 by Medical Doctor (MD) #500 revealed the recommendation to continue Eliquis therapy due to history of pulmonary embolism. Review of the physician orders for Resident #56 in June 2022 revealed an order for Eliquis 5 mg twice daily from 06/10/22 through 06/17/22. The order was discontinued after 06/17/22. Review of the medication administration record (MAR) for Resident #56 in June 2022 confirmed the facility was giving the Eliquis 5 mg from 06/10/22 through 06/17/22. No doses of the medication were noted from 06/18/22 through 06/23/22. Interview on 06/23/22 at 10:00 A.M. with the Director of Nursing (DON) confirmed that Resident #56 had not received Eliquis 5 mg from 06/18/22 through 06/23/22. Interview on 06/23/22 at 12:50 P.M. with MD #500 revealed that he was unaware that the order for Eliquis 5 mg twice daily for Resident #56 was not being given since 06/17/22. MD #500 confirmed that he wanted the resident to be receiving the medication due to a history of pulmonary embolism. The medical doctor went on to say that any medication ordered by the hospital at discharge should be continued. MD #500 also stated that it would be hard to say how it would affect Resident #56, but there would be that potential for harm based on a history of pulmonary embolism. The medical doctor referred to the mistake as an oversight by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 6 of 11 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 06/27/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #07 revealed admission date of 01/22/20 and a readmit date of 04/29/22. Diagnoses included, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene, glaucoma secondary to other eye disorders, bilateral, chronic pain syndrome, aphasia, dysphagia, corns and callosities, nail dystrophy, traumatic amputation of one right lesser toe, and cerebral infarction to unspecified occlusion or stenosis of right carotid arteries. Residents Affected - Few Review of the annual MDS dated [DATE] revealed the resident had impaired cognition. The resident required extensive one-person physical assistance for personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands. The resident was independent with setup help only for eating. The resident had functional limitations in range of motion with impairment on one side of upper and lower extremities. The resident had weight loss and was not on a prescribed weight-loss regimen. The resident had a therapeutic diet. Review of the Plan of Care dated 05/03/22 revealed the resident needed assistance for Activities of Daily Living (ADLs) related to impaired cognition, impaired mobility, and generalized weakness. Interventions included the resident required supervision with set up assist for eating. The resident had the potential for a decline or alteration in his nutrition and/or hydration related to: history of Barrett's esophagus, potential for hyper/hypoglycemia related to diabetes, renal failure. Appetite is good to excellent. Monitor weight every month and as needed. Notify physician/Nurse Practitioner (NP) of significant weight changes. Record consumption of meals, including fluid intake. Review of Dietary Progress dated 06/09/22 at 2:57 P.M. revealed reweight obtained 06/06/22 154.6 pounds, Body Mass Index (BMI) 23.5, triggering for significant loss of -11.6%/20.4 pounds times 180 days. Oral intake is greater than 50% at most meals per nursing. Boost Plus daily, typically 100% intake, providing 360 kilocalories (kcal), 14 grams protein. BMI-normal range. Recommending to continue with weekly weights. Speech Language Pathologist (SLP) following related to dysphagia. He is self-feeding with setup assist. Recommendations: continue Boost Plus, weekly weights. Review of physician orders dated 05/09/22 revealed weekly weights, one time a day every Monday, start date 05/16/22. Review of weight documentation revealed weights on 05/30/33, 06/06/22, 06/20/22 and 06/22/22. Weight documentation was silent on 05/16/22, 05/23/22, and 06/13/22. This finding was verified on 06/23/22 at 9:17 A.M. with RD #225. Review of facility policy titled, Weight Policy, revised date 11/2018, revealed it is the policy of this facility to attain/maintain a resident's weight within the recommended range as appropriate in relation to their medical and physical status. Weights will be obtained in a timely manner, documented and responded to appropriately. A. Admissions and Readmissions: 1. Weights will be obtained upon admission and documented. Do not use the hospital weight. 2. The resident will be weighed every week for the following three weeks, then monthly unless ordered by physician (MD)/ Nurse Practitioner (NP) or dietician. B. Reweights: 1. If a reweight shows the same of greater weight variance as above, a nurse will verify the weight was obtained correctly, and the weight of the wheelchair, cushions, splints or other items was taken into consideration as appropriate. C. The dietician will be notified of significant changes in weights, insidious weight loss and other concerns related to diet and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 7 of 11 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 06/27/2022 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intake. Acute of chronic wight changes will be documented and recommendations will be provided by the dietician as appropriate. D. The dietician will work with the facility staff during the routine weight meeting to review resident weight trends and determine any additional interventions for the resident's weight change. F. The physician and responsible party will be made aware of significant changes in weight. Based on record review, interviews and policy and procedure review the facility failed to obtain weights for residents as per physician orders . This had the potential to affect three residents (#07, #42 and #58) out of three residents who were reviewed for possible weight loss. The facility census was 73. Findings include: 1. Review of medical record for Resident #42 revealed admission date of 12/03/21 with mild cognitive deficits . He was admitted with a diagnoses of arteriovenous fistula, repeated falls, diabetic and chronic kidney disease. A review of Resident #42 physician orders from 05/1/22 to 06/23/22 revealed on 05/22/22 an order for weights to be done for three days and then weekly on Sunday for three weeks. A review of Resident #42 weights for 04/01/22 to 06/30/22 revealed weights were not recorded on 05/23/22, 05/24/22, 05/25/22 or on Sunday 06/03/22. On 06/23/22 at 1:00 P.M. interview with the DON confirmed weights for Resident #42 were not done on 5/23/22, 5/24/22, 5/25/22 , or on Sunday 06/03/22. 2. Review of the medical record of Resident #58 revealed an original admission date of 04/20/21. The resident had hospital stays from 09/23/21-10/13/21, 03/16/22-03/20/22, and 04/29/22-05/03/22. The most recent and uninterrupted readmission for Resident #58 occurred on 05/03/22. Diagnoses included dependence on ventilator, dehydration, hypokalemia, dysphagia, anemia, hypertension, and anxiety disorder. Review of the quarterly minimum data set (MDS) assessment for Resident #58 dated 05/06/22, revealed the resident had an intact cognition. No hallucinations, delusions, or rejection of care were noted in the assessment. Resident #58 required supervision with eating. The assessment noted that the resident was not noted to be holding foods or liquids in her mouth. Resident #58 was noted to have no broken teeth or mouth pain and was on a mechanically altered diet. The assessment also noted no significant weight loss. The resident was on a weight gain regimen prescribed by the doctor. Review of the plan of care for Resident #58 dated 05/05/22 revealed the resident had a potential for alteration in nutrition related to the history of protein-calorie malnutrition. Interventions included monitoring weight every month and as needed, following doctors' orders, and offering meal substitutes for dislikes. Review of the readmission weight for Resident #58 dated 05/03/22 revealed a weight of 138.5 pounds (lbs.). No other weights were recorded from 05/03/22 through 06/22/22. Review of the facility documentation completed for Resident #58 regarding amount eaten revealed from 05/25/22 through 06/23/22 the resident at 50% or less of her meal 10% of the time. No (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 8 of 11 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 06/27/2022 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 0692 Level of Harm - Minimal harm or potential for actual harm documentation was completed by facility staff for 55% of the meals eaten by Resident #58 during that time period. Review of the physician orders for Resident #58 revealed orders for weekly weights on Mondays from 05/16/22-current. Residents Affected - Few Interview on 06/23/22 at 9:20 A.M. with Registered Dietician (RD) #225 confirmed no other weights had been completed for Resident #58 since 05/03/22. RD #225 also confirmed that the resident was ordered weekly weights on 05/16/22 and the order was not carried out by facility staff. The expectations of the dietician are that facility staff would carry out doctors' orders for weights. RD #225 stated that she could monitor the resident's nutritional status in other ways such as looking at food intakes recorded by the facility for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 9 of 11 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 06/27/2022 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the closed medical record revealed Resident #71 was admitted on [DATE] and discharged on 04/29/22. Diagnoses included dependence on renal dialysis, generalized abdominal pain, type one diabetes mellitus with diabetic autonomic (poly) neuropathy, diabetes mellitus due to underlying conditions with ketoacidosis without coma, type one diabetes mellitus without complications, type two diabetes mellitus with diabetic neuropathy, acute pancreatitis without necrosis or infection, disorder of the kidney or ureter, gastroparesis, depression, bipolar disorder, acquired absence of eye, hypoglycemia, acute kidney failure, mixed irritable bowel syndrome, cognitive communication deficit, muscle weakness, anxiety disorder, unsteadiness on feet, schizoaffective disorder, essential (primary) hypertension, autoimmune hepatitis, and end stage renal disease. Residents Affected - Few Review of the MDS assessment, dated 04/15/22, revealed the former resident was cognitively intact. Review of physician orders, dated 04/12/22, revealed Resident #71 was scheduled for dialysis every Monday, Wednesday, and Friday for pick-up at 6:30 A.M. Review of physician orders, current April 2022, revealed Resident #71 received the following medications upon rising: amlodipine besylate tablet 10 mg, furosemide tablet 20 mg give 40 mg one time a day, metoprolol succinate extended release tablet 50 mg, clonazepam tablet 0.5 mg, Levemir flex touch solution pen-injector 100 unit/milliliter (ml) inject 15 unit subcutaneously two times a day, protonix tablet delayed release 40 mg, and Humalog kwikpen solution pen-injector 100 unit/ml inject eight unit subcutaneously with meals. Review of the Medication Administration Record (MAR), dated April 2022, revealed all medications prescribed upon rising were not provided on Wednesday 04/20/22, Saturday 04/23/22, Monday 04/25/22, Wednesday 04/27/22, and Friday 04/29/22. The reason provided was absent from home. Interview on 06/23/22 at 11:09 A.M. with Director of Nursing (DON) verified there was no documentation Resident #71 received morning medications, including insulin, on 04/20/22, 04/23/22, 04/25/22, 04/27/22, and 04/29/22. Interview on 06/23/22 at 1:38 P.M. with Licensed Practical Nurse (LPN) #49 verified providing care to Resident #71 on 04/20/22, 04/23/22, 04/25/22, 04/27/22, and 04/29/22. LPN #49 revealed first shift began at 7:00 A.M. and upon the beginning of the shift Resident #71 had left the building for dialysis. LPN #49 verified the prior shift should have provided the medication upon rising and prior to Resident #71 leaving for dialysis. This deficiency substantiates Complaint Number OH00132228, Complaint Number OH00114977, and Complaint Number OH00114226. Based on record review and staff interview the facility failed to pass medications as ordered resulting in significant medication errors. This affected two residents (#56 and #71) out of three residents reviewed for medications. The facility census was 73. Findings included: 1. Review of the medical record for Resident #56 revealed an original admission date of 01/12/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 10 of 11 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 06/27/2022 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The resident had hospital stays from 01/13/22-01/20/22, 01/22/22-02/02/22, 02/11/22-02/15/22, and 06/07/22-06/09/22. Diagnoses included dependence on respirator, viral pneumonia, type 2 diabetes mellitus, muscle weakness, urinary tract infection, and schizoaffective disorder. Review of the quarterly minimum data set (MDS) assessment for Resident #56 dated 06/10/22 revealed the resident had an intact cognition. No hallucinations, delusions, or rejections of care were noted by the assessment. Resident #56 required total dependence from at least one staff member for hygiene, toileting, dressing, locomotion on/off unit, and transfers. The resident required extensive assistance from staff for bed mobility and supervision with eating. Review of the hospital paperwork for Resident #56 dated 06/09/22 revealed an order to continue Eliquis (Blood thinner) 5 milligram (mg) tablet twice daily via g-tube or PEG tube. Review of the follow up progress note for Resident #56 written on 06/10/22 by Medical Doctor (MD) #500 revealed the recommendation to continue Eliquis therapy due to history of pulmonary embolism. Review of the physician orders for Resident #56 in June 2022 revealed an order for Eliquis 5 mg twice daily from 06/10/22 through 06/17/22. The order was discontinued after 06/17/22. Review of the medication administration record (MAR) for Resident #56 in June 2022 confirmed the facility was giving the Eliquis 5 mg from 06/10/22 through 06/17/22. No doses of the medication were noted from 06/18/22 through 06/23/22. Interview on 06/23/22 at 10:00 A.M. with the Director of Nursing (DON) confirmed that Resident #56 had not received Eliquis 5 mg from 06/18/22 through 06/23/22. Interview on 06/23/22 at 12:50 P.M. with MD #500 revealed that he was unaware that the order for Eliquis 5 mg twice daily for Resident #56 was not being given since 06/17/22. MD #500 confirmed that he wanted the resident to be receiving the medication due to a history of pulmonary embolism. The medical doctor went on to say that any medication ordered by the hospital at discharge should be continued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 11 of 11