Inspection·November 4, 2021

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the facility failed to ensure call lights were within reach and accessible for Resident's #12, #19, #81 and #59. This affected four residents (#12, #19, #81 and #59) of 133 residents reviewed for call light placement. Residents Affected - Some Findings include: 1. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left side, dementia, diabetes mellitus, and bipolar. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had intact cognition and required extensive assistance of activities of daily living. Observation and interview on 11/01/21 at 9:26 A.M. revealed Resident #12's call light was dangling on the left side of bed. Resident #12 did not know where it was and couldn't reach it. Resident #12 stated she uses the call light when she can get to it. Interview with State Tested Nursing Assistant (STNA) #118 at time of observation verified the call light was out of reach, and Resident #12 would be able to use the call light if it was within reach. 2. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including dementia, progressive supranuclear ophthalmoplegia dysarthria and anarthria. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #19 had intact cognition and required extensive assistance of activities of daily living. Observation on 11/01/21 at 9:33 A.M. revealed Resident #19's call light was on the floor. Interview with Registered Nurse (RN) #247 at time of observation verified the call light was out of reach. 3. Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including chromic kidney disease, diabetes mellitus, dementia, and major depressive disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #59 had severe cognitive impairment and required extensive assistance of activities of daily living. Observation on 11/01/21 at 9:29 A.M. revealed Resident #59's call light was on the floor. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 366229 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 366229 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Villa 7040 Hepburn Road Middleburg Heights, OH 44130 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)