Health inspection·April 3, 2023

F 0700 Level of Harm - Actual harm Residents Affected - Few Review of a nurse progress note for Resident #14 dated 03/24/23 at 8:05 A.M. per Licensed Practical Nurse (LPN) #105 revealed a nurse aide notified the nurse of the resident's fall. Upon entry to room, Resident #14 was partially on floor and partially on the bed with his head positioned on the lateral portion of the bed with the bed's grab bar touching face and neck. Due to the resident's position, he was unable to speak. Staff repositioned Resident #14 on the floor for comfort and ease of breathing. The unit manager called 911. While awaiting emergency personnel arrival, the resident was alert, speaking, and answering questions appropriately. Resident #14's vital signs were taken and were within normal limits. Review of the March 2023 monthly physician's orders for Resident #14 revealed an order dated 03/24/23 at 1:23 P.M. for the resident to have bilateral grab bars to his bed. Review of the side rail assessment for Resident #14 dated 03/24/23 at 1:32 P.M. revealed resident had bilateral grab bars to his bed to assist with mobility. The side rail assessment was completed after Resident #14 had been transferred to the hospital due to his head becoming entrapped between the mattress and the grab bar. The assessment did not include an alternative to the use of grab bars was attempted nor did it address the risk of entrapment. Review of the hospital notes for Resident #14 dated 03/24/23 through 03/31/233 revealed the resident was admitted to the hospital on [DATE] with an admitting diagnosis of trauma and penetrating injury to the neck. Resident #14 presented in the emergency department from the facility after a fall in which the resident was reported to have been found between the railing of his bed after a fall. Results of magnetic resonance imaging (MRI) performed on 03/25/23 indicated Resident #14 sustained an injury to the interior longitudinal ligament at the cervical (C6-C7) disc interspace without spinal cord injury which the hospital physician believed was sustained during the fall on 03/24/23. Neurosurgery was consulted while Resident #14 was in the hospital and recommended non-operative management of the injury. Resident #14 wore a hard cervical collar which was ordered to be maintained for two weeks, and then he was to follow up with neurosurgery. While in the hospital, Resident #14 had a gastrostomy tube (a tube placed directly into the stomach) placed and was a nothing by mouth (NPO) status due to concern for esophageal injury. Review of the facility's investigation of Resident #14's fall on 03/24/23 revealed Maintenance Director (MD) #100 assessed Resident #14's bed on 03/24/23 at 9:00 A.M., and determined it was in working order with no malfunctioning of equipment noted. Further review of the investigation revealed it did not address assessment of Resident #14's beds for entrapment risk. Review of a written statement for State Tested Nursing Assistant (STNA) #125 dated 03/24/22 revealed the aide entered Resident #14's room on 03/24/23 at approximately 8:00 A.M. and noted the resident's head was stuck in the side rail and his body was on the floor. Further review of statement revealed STNA #125 saw blood on Resident #14's face and he was shaking, wet, and cold, and the nurse aide called the nurse who assisted in moving the resident. Review of a written statement for STNA #385 dated 03/24/23 revealed at approximately 8:00 A.M. Resident #14's call light was sounding, and she entered the room and found the resident with his body on the ground and his head stuck in the bed rail. STNA #385 called for STNA #125 and the nurse and the nurse aides assisted with repositioning Resident #14's body on the floor while the nurse removed the resident's head from the bed. STNA #385 confirmed Resident #14 was gurgling and she was concerned about Resident #14 choking while waiting for 911 to arrive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 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 365363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 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 0700 Level of Harm - Actual harm Residents Affected - Few Review of a written statement for LPN #105 dated 03/24/23 revealed the nurse aides called her to Resident #14's room on 03/24/23 at approximately 8:00 A.M., and the resident was found with his body on the floor and his head between the bed and the grab bar. Resident #14 complained of hip pain and there was a one inch laceration noted to his neck with a small amount of blood. The nurse and nurse aides assisted the resident to the floor and 911 was called. Interview on 03/31/23 at 9:31 A.M., with LPN #105 confirmed on 03/24/23 at approximately 8:00 A.M. the nurse aide told her Resident #14 was on the floor. LPN #105 entered the resident's room and found Resident #14 with his head on the grab bar on the left side of the bed and his body was on the ground. LPN #105 confirmed she lifted Resident #14's head up and placed it on a pillow on the floor while the nurse aides repositioned Resident #14's body. Resident #14 had a small laceration to the right side of his neck that was bleeding. The unit manager, LPN #150, called 911. Resident #14 complained of hip pain and his vital signs were stable. Interview on 03/31/23 at 9:40 A.M., with LPN #150 confirmed she called 911 on 03/24/23 because she was told Resident #14 got his head stuck between his side rail and the mattress. LPN #150 confirmed when she entered Resident #14's room on 03/24/23 at approximately 8:05 A.M., another nurse and two nurse aides were with him, and he was lying on the floor on his left side with his head on a pillow. LPN #150 confirmed she was unsure when the grab bars were installed on the resident's bed. LPN #150 confirmed the physician's order for grab bars and the side rail assessment for Resident #14 were completed on 03/24/23 after Resident #14 had been taken to the hospital. Interview on 03/31/23 at 10:00 A.M., with the Director of Nursing (DON) confirmed Resident #14 had a fall on 03/24/23 in which his head was wedged between the mattress and the grab bar. DON confirmed the resident was sent to the hospital on [DATE] via 911, and Resident #14 was admitted to the hospital. DON further confirmed she was unsure of Resident #14's admitting diagnosis or if he had sustained any injuries related to the incident. DON confirmed she heard Resident #14 planned to discharge back to the facility on [DATE]. Interview on 03/31/23 at 10:05 A.M., with MD #100 confirmed he assessed Resident #14's bed on 03/24/23 at approximately 9:00 A.M. per the Administrator's request because he heard the resident got stuck between the mattress and the grab bar of his bed. MD #100 confirmed he installed the grab bars to Resident #14's bed approximately one week prior to incident on 03/24/23. MD #100 confirmed when he inspected Resident #14's bed he determined the bed was in good working order, the grab bars were compatible with the resident's bed, and were installed properly per manufacturer's instructions. MD #100 confirmed his routine maintenance and inspection of beds did not include assessing for possible entrapment risk. Interview on 03/31/23 at 10:18 A.M., with the Administrator confirmed he was not aware if Resident #14 had sustained any injuries related to his fall on 03/24/23. Administrator further confirmed the resident was taken to the hospital via 911 and admitted on [DATE] because he got his head stuck between the bed rail and the mattress. Administrator confirmed Resident #14 was still in the hospital and he heard Resident #14 was possibly going to return to the facility on [DATE]. Interview on 03/31/23 at 10:22 A.M., with STNA #125 confirmed STNA #385 called her to Resident #14's room on 03/24/23 at approximately 8:00 A.M. STNA #125 confirmed the resident was on the floor on the left side of the bed and the mattress was slid over a bit. Resident #14 was gurgling, and he had blood on his face. Resident #14's body was on the floor on the left side of the bed tangled up in a blanket and his head was facing the floor with his head stuck between the grab bar and the mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 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 365363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 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 0700 Level of Harm - Actual harm Residents Affected - Few Resident #14 indicated his neck was hurting. The nurse aide did not move the resident but waited for LPN #105 to assess him. The nurse aides assisted with repositioning Resident #14's body on the floor while LPN #105 lifted his head up and placed it on a pillow on the floor. Observation of Resident #14's bed on 03/31/23 at 12:03 P.M., with MD #100, revealed the bed, air mattress, and grab bars were all from the same manufacturer. The air mattress was in place and functioning and was secured to the bed frame with ties provided by the manufacturer. The grab bars were in place to the bilateral upper sides of the bed. When the mattress was pushed to the right side of the bed a three-to-three-and-a-half-inch gap between the mattress and left grab bar was measured. This was confirmed with MD #100 who used a tape measure to take the measurement. Interview on 03/31/23 at 12:03 P.M., with MD #100 confirmed Resident #14's bed had not been altered since he left for the hospital on [DATE]. MD #100 stated the facility planned for Resident #14 to return to the same room with the same bed, air mattress, and grab bars when he was readmitted to the facility. Review of Food and Drug Administration (FDA) document titled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 03/10/06, revealed for 20 years, the FDA had received reports in which vulnerable patients had become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment described an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or bed frame. Resident entrapments might result in deaths and serious injuries. The population most vulnerable to entrapment was elderly patients and residents, especially those who were frail, confused, restless, or who had uncontrolled body movement. Entrapments have occurred in a variety of patient care settings, including hospitals, nursing homes, and private homes, and long-term care facilities reported the majority of the entrapments. Reducing the risk of entrapment involved a multi-faceted approach that included bed design, clinical assessment and monitoring, as well as meeting the needs for vulnerable residents. Review of manufacturer's guidelines for the bed and grab bars in use for Resident #14 dated 04/01/18 revealed accurate assessment of the resident and monitoring of correct maintenance and equipment use were required to prevent entrapment. Review of the facility policy titled, Proper Use of Bed Rails, dated 10/01/22, revealed alternative approaches should be attempted prior to installing or using bed rails. If bed rails are used, the facility should ensure correct installation, use, and maintenance of the rails. The following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: medical diagnosis, conditions, symptoms, and or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, cognition, communication, mobility in and out of bed, risk of falling. The assessment must include an evaluation of the alternatives that were attempted prior to the installation or the use of a bed rail. Examples of potential hazards included entrapment. The facility should inspect and regularly check the mattress and the bed rails for areas of possible entrapment. The facility should ensure the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth. This deficiency represents non-compliance investigated under Master Complaint Number OH00141602 and Complaint Number OH00141506. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 4 of 4