Health inspection·August 1, 2023

F 0686 was at risk for the development of pressure ulcers. Level of Harm - Actual harm Review of the nurse's skin grid dated 06/17/23 for Resident #44, revealed an unstageable pressure (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [dead, yellowish tissue] or eschar [dry, back hard necrotic tissue] and if the slough or eschar is removed, a Stage III or Stage IV will be revealed) to the resident's left flank which measured 9.0 centimeters (cm) in length by 5.0 cm in width with depth unable to be determined. The wound bed had green and yellow slough in the middle. Residents Affected - Few Review of the nurse's skid grid dated 06/19/23 for Resident #44, revealed an unstageable pressure ulcer to the resident's left flank first identified on 06/17/23 which measured 3.0 cm in length by 3.7 cm in width with depth unable to be determined. The wound bed consisted of 10 percent (%) granulation tissue, 10% slough, and 80% eschar. The wound had approximated edges, a moderate amount of tan and green and yellow colored drainage. Review of the wound physician progress note dated 06/21/23 for Resident #44, revealed the resident had a newly identified unstageable pressure ulcer to the left flank first identified on 06/17/23 which measured 3.4 cm. in length by 5.2 cm. in width with depth unable to be determined. The composition of the wound bed tissue at the beginning of the visit was 50% granulation, 15% slough, and 35 % eschar. The wound physician performed a sharp debridement (surgical procedure of the wound with sharp instruments where devitalized tissue is removed) at the bedside using a curette to remove eschar and slough tissue and used benzocaine spray to control resident's pain during the procedure. Following the debridement procedure, the unstageable pressure area was recategorized as a stage III pressure ulcer (full thickness loss of skin, in which fat tissue is visible.) Observation of wound care on 08/01/23 at 9:11 A.M. for Resident #44 per Licensed Practical Nurse (LPN) #392, revealed the resident was resting on a pressure reduction mattress. Observation revealed the resident had a dime-sized healing pressure ulcer to the left flank. Interview with LPN #630 on 08/01/23 at 2:39 P.M. confirmed she participated in wound rounds with the wound physician, and she completed the skin grid for Resident #44 on 06/19/23. LPN #630 confirmed skin observations should be performed weekly by a licensed nurse, and Resident #44 had no skin observations recorded from 06/02/23 until 06/17/23 when the resident was found to have an unstageable pressure ulcer to his left flank. LPN #630 confirmed the pressure ulcer should have been identified before it had reached an advanced stage. LPN #630 confirmed she assisted the wound physician on 06/21/23 when he had to perform a sharp debridement on Resident #44 in order to remove the eschar and slough tissue from the wound. Interview with LPN #630 on 08/01/23 at 3:15 P.M. confirmed the State Tested Nursing Assistants (STNAs) had showered and completed the shower sheets for Resident #44 during the time period of 06/02/23 to 06/17/23 and the STNAs did not identify any new skin areas for the resident. LPN #630 confirmed the shower sheets did not take the place of a nurse's assessment for the resident's skin. 2. Review of the closed medical record for Resident #74 revealed an admission date of 07/07/23 with diagnoses including diabetes mellitus (DM), cerebral infarction, acute respiratory failure with hypoxia, asthma, hypertension, sleep apnea, atherosclerotic heart disease, and recent acute myocardial infarction and a discharge date of 07/14/23. Review of the admission assessment/baseline care plan dated 07/07/23 for Resident #74, revealed the (continued on next page) 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 08/01/2023 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 0686 resident had no areas of skin impairment and there were no documented interventions for the prevention of skin breakdown for resident. Level of Harm - Actual harm Residents Affected - Few Review of the pressure ulcer risk assessment dated [DATE] for Resident #74, revealed the resident was at very high risk for the development of pressure ulcers. Review of the July 2023 Treatment Administration Record (TAR) for Resident #74, revealed it included weekly skin check for resident signed off as completed on 07/09/23; however, there were no other interventions or treatments included in the TAR for prevention of skin breakdown. Review of the nurse's weekly skin observation dated 07/09/23 for Resident #74, revealed the resident had no areas of skin impairment. Review of the MDS assessment dated [DATE] for Resident #74, revealed the resident was cognitively impaired, required extensive assistance of staff with ADLs, and was assessed as having a stage II pressure ulcer (partial thickness loss of skin with exposed dermis) which was not present upon admission. Review of the comprehensive care plan dated 07/14/23 for Resident #74, created after the resident had discharged , revealed the resident had an actual area of skin impairment related to pressure ulcer. The care plan goals and interventions had not been entered at the time of resident's discharge from the facility. Review of the nurse progress note dated 07/14/23 for Resident #74, revealed the resident was noted with a new superficial open area to his right buttock. Review of the nurse's skin grid dated 07/14/23 for Resident #74, revealed the resident had a stage II pressure ulcer to his left buttock which measured 1.4 cm in length by 1.4 cm in width by 0.1 cm in depth. The pressure ulcer was described as a superficial open, reddened area without drainage. Interview with LPN #554 on 08/01/23 at 8:40 A.M. confirmed Resident #74 was assessed upon admission as being at very high risk for the development of pressure ulcers. LPN #554 confirmed the resident's admission skin assessment indicated resident had no skin breakdown, and the resident's baseline care plan had no documented interventions implemented to prevent skin breakdown. LPN #554 indicated the care plan included an update on 07/14/23 indicating the resident had developed a Stage II pressure ulcer. LPN #554 confirmed the facility had conducted a weekly skin observation for Resident #74 on 07/09/23, but also confirmed the facility conducted weekly skin observations per licensed nurses for all residents, and resident #74 had no individualized interventions put in place related to his very high risk of pressure ulcer development. Review of the facility policy titled Pressure Injury Prevention and Management dated 08/20/22 revealed the facility was committed to the prevention of avoidable pressure injuries. The facility defined avoidable as the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the intervention and revise the interventions as appropriate. Licensed nurses would conduct full body skin assessments for all residents weekly. Evidence-based interventions for prevention would be implemented for all residents who were assessed at risk or who had a pressure injury present. (continued on next page) 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 08/01/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Numbers OH00144957 and OH00144740. 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 08/01/2023 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 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 record review, staff interview, review of the facility policy, and review of medication information from Medscape (online resources), the facility failed to ensure a resident was free from unnecessary medications by failing to implement adequate blood sugar monitoring in conjunction with insulin administration. This affected one resident (#57) of three residents reviewed for diabetes management. The census was 73. Residents Affected - Few Findings include: Review of the medical record for Resident #57 revealed an admission date of 03/03/22 with a diagnosis of diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #57, revealed the resident was cognitively impaired and was totally dependent on the assistance of one to two with activities of daily living (ADL's). Review of the care plan dated 03/03/22 for Resident #57, revealed the resident was at risk for hyper/hypoglycemia due to diagnosis of DM. Interventions included the following: administer medications as ordered, be alert for signs and symptoms of hypoglycemia and hyperglycemia, lab work as ordered, obtain blood sugar levels as ordered, and provide diet as ordered. Review of the laboratory (lab) work for Resident #57, revealed the most recent hemoglobin A1C (measures blood sugars over a three-month period) was drawn on 03/04/22 and was noted to be high at 8.0, which indicated a poor blood sugar control. Review of Nurse Practitioner (NP) #725 progress note dated 02/10/23 for Resident #57, revealed the resident was receiving insulin for DM with a goal of maintaining a blood sugar less than 200. Review of the physician orders for Resident #57 dated 03/06/23, revealed an order to inject 16 units of insulin glargine (long-acting insulin) subcutaneously two times daily for treatment of DM. Further review of the physician orders revealed no physician orders to check the resident's blood sugar via fingerstick. Review of the vital signs section for Resident #57, revealed the most recent blood sugar recorded for the resident was taken on 05/02/23, and the blood sugar was 119. Review of the May, June, and July 2023 Medication Administration Records (MARs) for Resident #57, revealed the resident received glargine insulin twice daily. The MAR revealed no documented evidence Resident #57 had any fingerstick blood sugars taken. Review of Physician #750's progress note dated 06/28/23 for Resident #57, revealed the resident was receiving insulin for DM with a goal of maintaining a blood sugar less than 200. Interview on 08/01/23 at 11:52 A.M. with Licensed Practical Nurse (LPN) #554 confirmed Resident #57's last documented blood sugar was on 05/02/23. LPN #554 confirmed a blood sugar level should be checked per the physician's order. LPN #554 confirmed Resident #57 received insulin twice daily, but the nurses were not checking the residents blood sugar. LPN #554 confirmed Resident #57's last Hemoglobin A1C labs related to her DM was completed on 03/04/22 and it was high at 8.0. (continued on next page) 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 08/01/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/01/23 at 12:48 P.M. with NP #725, confirmed she had not examined the resident since 02/10/23, but she knew the resident was a diabetic who took insulin twice daily. NP #725 confirmed that generally residents on insulin should have their blood sugar levels checked once weekly at a minimum. Interview on 08/01/23 at 2:11 P.M. with Physician #750, confirmed Resident #57 was a diabetic who received insulin twice daily and her goal was to maintain blood sugar levels below 200. Physician #750 indicated Resident #57 should have her blood sugars checked at least once weekly. Review of the undated facility policy titled Nursing Care of the Resident with DM revealed the physician will order the frequency of glucose monitoring. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation. Review of patient handout for insulin glargine per online resource Medscape at (https://reference.medscape.com/drug/lantus-toujeo-insulin-glargine-999003#9) revealed individual taking insulin glargine should monitor blood sugar on a regular basis, keep track of the results, and share them with their doctor. This deficiency represents non-compliance investigated under Complaint Numbers OH00144957 and OH00144740. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365363 If continuation sheet Page 6 of 6