Inspection·April 30, 2024

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 Based on record review, observation, interview, policy review, and review of the Centers for Disease Control and Prevention guidance, the facility failed to test blood glucose levels appropriately. This affected one (#12) of six residents reviewed for blood glucose testing. Residents Affected - Few Findings include: Review of the medical record for Resident #12 revealed an admission date of 04/16/24. Diagnoses included type two diabetes, joint replacement surgery, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 04/23/24, revealed Resident #12 had intact cognition. Review of the physician order dated 04/17/24 revealed an order to administer insulin with meals and at bedtime per sliding scale based on blood glucose levels. Observations of medication administration on 04/29/24 at 8:37 A.M. revealed Licensed Practical Nurse (LPN) #200 checking a blood glucose level for Resident #12. Resident #12 had already consumed breakfast. Resident #12's blood sugar level was 206 which indicated the resident was to receive four units of insulin per sliding scale. LPN #200 confirmed the blood glucose was obtained after Resident #12 consumed his breakfast; she stated she was late getting to the floor. LPN #200 stated blood glucose levels were to be obtained before meals. Interview on 04/30/24 at 4:16 P.M. with the Director of Nursing confirmed blood glucose levels were to be obtained before meals were consumed. Review of the facility policy titled Blood Glucose Testing, dated 2023, revealed to test glucose levels as ordered. The policy did not indicate to check blood glucose levels before meals. Review of the CDC guidance obtained from https://www.cdc.gov/diabetes/managing/manage-blood-sugar.html revealed how often you check your blood sugar depends on the type of diabetes you have and if you take any diabetes medicines. Typical times to check your blood sugar included: • When you first wake up, before you eat or drink anything. • Before a meal. (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 04/30/2024 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)