Inspection·July 26, 2023

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #156's Lyrica pain medication was available for administration to meet the needs of the resident and the medical record accurately reflected the pain medication administered. This finding affected one (Resident #156) of four residents reviewed for medication administration. Residents Affected - Few Findings include: Review of Resident #156's medical record revealed the resident was admitted on [DATE] and discharged home on [DATE] with diagnoses including diabetes, spinal stenosis and Guillain-Barre syndrome (a rare disorder in which your body's immune system attacks your nerves). Review of Resident #156's Minimum Data Set (MDS) 3.0 assessment revealed the resident exhibited intact cognition. Review of Resident #156's physician orders revealed an order dated [DATE] for Lyrica (used to treat pain caused by nerve damage) 225 mg (milligrams) give one capsule every twelve hours for pain due at 09:00 A.M. and 9:00 P.M. Review of Resident #156's Lyrica 225 mg Controlled Drug Administration Record form with administration dates from [DATE] to [DATE] revealed 30 tablets were delivered to the facility and the last dose was administered on [DATE] at 9:48 P.M. Review of Resident #156's medication administration records (MARS) from [DATE] to [DATE] revealed Lyrica pain medication due on [DATE] at 9:00 A.M. was documented as administered and the dose due on [DATE] at 9:00 P.M. was documented as OT. The MARS indicated OT was the documentation code for other. Review of Resident #156's medication pass progress note dated [DATE] at 8:33 PM. revealed Lyrica 225 mg give one capsule by mouth every twelve hours was on hold and waiting on pharmacy. Review of Resident #156's certified nurse practitioner (CNP) progress note dated [DATE] at 9:23 A.M. revealed the patient was seen at the request of nursing for complaints of numbness and tingling. On exam, the patient was concerned about worsening numbness and tingling to the upper and lower extremities. He stated he had been taking Lyrica for 7.5 years and never missed a dose. The prescription was renewed per a discussion with nursing and the medication was delivered to the unit while the CNP was on the unit. (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 2 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 07/26/2023 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)