Inspection·November 7, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interviews with facility and hospital staff, the facility failed to ensure Resident #170 was provided a bed hold notice when discharged to the hospital. This affected one resident (Resident #170) of three residents reviewed for bed hold notices. Findings include: Review of the closed medical record for Resident #170 revealed an initial admission date of [DATE] then a readmission on [DATE]. He was discharged to the hospital on [DATE]. He expired on [DATE] at the hospital. Resident #170's diagnoses included heart transplant recipient, end stage renal disease and congestive heart failure. Review of the progress note dated [DATE] at 4:24 A.M. revealed a transfer and bed hold notice signed by the nurse. There was no evidence Resident #170 signed the notice or was given a written copy of the notice. Interview on [DATE] at 2:46 P.M. with Registered Nurse (RN) #201 revealed she did not have Resident #170 sign the bed hold notice nor have other evidence he received a copy in writing. Interview on [DATE] with the Hospital Social Worker (HSW) revealed the facility stated they could not take him back upon being ready for discharge. The first reason the facility sent via the electronic referral system at 11:30 A.M. was the facility was not able to meet his needs. The second response at 2:20 P.M. stated the resident went to the hospital for a procedure and chose to not hold the bed and they did not have any beds available. Interview on [DATE] at 12:44 P.M. with Transplant SW (TSW), who was working in conjunction with HSW, revealed Resident #170 would not have wanted to give up his bed because he would have lost his housing voucher and he also left his belongings at the facility with the intention of returning. Interview on [DATE] at 3:11 P.M. with HSW revealed Resident #170 said to her at one point I was joking with the staff that they better not give up my bed. He denied receiving anything in writing about discharge or bed hold. Review of the facility policy titled Notice of Bed Hold When Leaving the Facility, dated [DATE] revealed there may be situations, after one has left the facility when one may not be eligible for return/readmission to the facility. (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 11/07/2024 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)