Health inspection·December 29, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #50's physician orders revealed an order dated 07/14/23 for an 18 French Foley catheter change every month and as needed. Review of Resident #50's MDS 3.0 comprehensive assessment Section H - Bladder and Bowel dated 09/28/23 revealed the resident exhibited intact cognition, did not have an indwelling catheter, was frequently incontinent of urine and always incontinent of bowel. Review of Resident #50's Bowel and Bladder Assessment form dated 10/01/23 revealed the resident was frequently incontinent but some control was present. The Bowel and Bladder Assessment form did not accurately reflect the resident's Foley catheter usage. Observation and interview on 12/27/23 at 9:06 A.M. with Resident #50 revealed the resident had a urinary catheter in place and the resident reported he was unaware of the reason for the use of the catheter. Interview on 12/27/23 at 4:44 P.M. with RN MDS #801 confirmed Resident #50's MDS 3.0 comprehensive assessment did not accurately reflect the resident's Foley catheter usage and the Bowel and Bladder Assessment form did not accurately reflect the resident's Foley catheter use. 4. Review of Resident #51's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, hallucinations and depression. Review of Resident #51's physician orders revealed an order dated 12/15/22 for Hydrocodone-Acetaminophen tablet 5-525 mg (milligrams) give one tablet by mouth every six hours for pain management due at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of Resident #51's medication administration record from 12/01/23 to 12/15/23 revealed the resident was receiving the Hydrocodone-Acetaminophen narcotic tablets. Review of Resident #51's MDS 3.0 comprehensive assessment Section N - Medications dated 12/13/23 revealed the resident did not receive opioid narcotics. Interview on 12/28/23 at 10:50 A.M. with RN MDS #801 confirmed Resident #51's MDS 3.0 comprehensive assessment dated [DATE] did not accurately reflect the resident's narcotic medication administration. 5. Review of Resident 64's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including diabetes, acquired absence of the left leg above the knee and anxiety disorder. Review of Resident #64's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. The medical record did not reveal evidence of a discharge comprehensive assessment. Review of Resident #64's social service progress note progress note dated 09/26/23 at 12:36 P.M. revealed the staff successfully moved the resident to the new assisted living unit per his choice. Interview on 12/28/23 at 8:58 A.M. with RN MDS #801 confirmed Resident #64 was discharged to the assisted living and the facility should have completed a discharge return not anticipated MDS for this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 2 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident which was not completed.6. Review of the medical record for Resident #56 revealed an admission date of 06/01/21. Diagnoses included cerebral infarction, vascular dementia with other behavioral disturbance, psychosis, major depressive disorder, and anxiety. Review of the physician orders for December 2023 revealed orders for Lorazepam (antianxiety) tablet 0.5 milligrams (mg) to give one tablet by mouth three times a day for anxiety with a start date of 08/31/23. Review of the medication administration records for October 2023 and November 2023 revealed Resident #56 received Lorazepam (anti-anxiety) tablet 0.5 mg as ordered. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed Resident #56 had impaired cognition and did not receive any anti-anxiety medications during the seven day look back period. Interview on 12/28/23 at 10:51 A.M. with MDS Nurse #801 verified she marked no for anti-anxiety medication use and that it should be yes. MDS Nurse #801 stated Resident #56 received the medication routinely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 3 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 and interview, the facility failed to ensure Resident #15's sacral pressure ulcer wound dressing was in place. This finding affected one (Resident #15) of two residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including cerebral atherosclerosis, depression and anxiety. Review of Resident #15's physician orders revealed an order dated 11/17/23 to cleanse the area to the coccyx with normal saline, apply a collagen sheet to the wound bed, apply calcium alginate, apply skin prep to the peri wound and cover with a silicone super absorbent border foam dressing three times a week and as needed every Monday, Wednesday and Friday for wound care. Review of Resident #15's wound progress note dated 12/13/23 revealed the resident had a stage four full thickness coccyx pressure wound which measured 2.6 cm (centimeters) by 0.9 cm by 1.1 cm with 10% slough and 90% granulation tissue. Observation on 12/27/23 at 3:09 P.M. with Licensed Practical Nurse (LPN) #811 and State Tested Nursing Assistant (STNA)/Transport #826 of Resident #15's coccyx pressure ulcer dressing change revealed the resident was turned to her side and the coccyx pressure ulcer dressing was not in place at the time of the observation. Interview on 12/27/23 at 3:14 P.M. with LPN #811 confirmed she was unsure what happened to Resident #15's dressing but it was not in place at the time of the observation. Review of the undated Pressure Ulcers/Skin Breakdown Clinical Protocol policy indicated the physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc) and application of topical agents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 4 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #51's fall interventions were implemented according to the physician orders and care plans. This finding affected one (Resident #51) of five residents reviewed for accidents and hazards. Findings include: Review of Resident #51's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, major depressive disorder and unspecified dementia. Review of Resident #51's physician orders revealed an order dated 10/29/22 to keep the bed in the lowest height when in bed and an order dated 12/04/23 for a perimeter mattress to the bed for safety. Review of Resident #51's Fall Investigation form dated 11/21/23 revealed the State Tested Nursing Assistant (STNA) found the resident on the floor by the bed. The resident could not state what he was doing. The fall interventions listed included a non-skid floor mat at the bedside and a low bed. The new intervention included to call hospice for a perimeter air mattress. Review of Resident #51's fall care planned interventions revealed interventions including the pressure relieving perimeter mattress to maintain safer bed boundaries, the bed in a low position and non skid footwear. The fall care planned interventions did not include a non-skid floor mat at the bedside. Review of Resident #51's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the resident exhibited intact cognition and had two or more falls with injury except major. Observation on 12/27/23 at 10:13 A.M. revealed Resident #51 was asleep on an air bed and no fall bolsters were present. His non-slip fall mat was observed pushed away from the bed in the middle of the room. Observation on 12/27/23 at 11:05 A.M. revealed Resident #51 was in bed sleeping. His fall mat was in the middle of the room and his bed appeared to be elevated at a normal height. Observation on 12/28/23 at 9:24 A.M. revealed Resident #51's bed was elevated to normal height, his overbed table was in front of him and he appeared to be sleeping. His non-slip fall mat was in the middle of the room. Observation on 12/28/23 at 9:44 A.M. with Licensed Practical Nurse (LPN) #811 revealed Resident #51's bed was at normal height and his non-slip fall mattress was in the middle of the room. Further observation revealed the resident was on an air mattress which did not have a perimeter overlay. Observation and interview on 12/28/23 at 9:52 P.M. with LPN Wound Nurse #802 confirmed Resident #51 was ordered a perimeter air mattress by hospice services and they sent bolsters which were to be put on underneath of the sheet. She stated the staff were unaware of what the bolsters were and did not implement them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 5 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 12/28/23 at 9:58 A.M. with the Director of Nursing (DON) stated she started to put in the order and the care planned intervention for the fall mat and she got busy. She stated the intervention was implemented and was not care planned timely. Review of the :Managing Falls and Fall Risk policy revised 03/2021 revealed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. Event ID: Facility ID: 366392 If continuation sheet Page 6 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 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 ensure Resident #51's narcotic pain medications were administered as ordered and failed to adequately monitor and assess Resident #51's pain levels prior to and following administration of the narcotic pain medications. This finding affected one (Resident #51) of two residents reviewed for pain management. Residents Affected - Few Findings include: Review of Resident #51's medical record revealed the resident wad initially admitted on 1214/21 and readmitted on [DATE] with diagnoses including major depressive disorder, pulmonary hypertension and hospice services. Review of Resident #51's Pain Level Summary form from 12/01/23 to 12/28/23 revealed the resident's pain was monitored on 12/16/23 at 12:33 A.M. with a pain level of ten (one being the least pain and ten the worst pain); on 12/16/23 at 7:51 A.M. with a pain level of five and on 12/28/23 at 12:34 P.M. with a pain level of eight. No other documentation was available related to assessment and monitoring of the resident's pain level. Review of Resident #51's physician orders revealed an order dated 12/15/22 for Hydrocodone-Acetaminophen tablet 5-325 mg (milligrams) give one tablet by mouth every six hours for pain management due at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of Resident #51's medication administration records (MARS) from 12/01/23 to 12/28/23 revealed no evidence the resident was administered the Hydrocodone-Acetaminophen narcotic pain medications on 12/03/23 at 6:00 A.M., 12/04/23 at 6:00 A.M., 12/05/23 12:00 A.M. and 6:00 A.M., 12/15/23 at 6:00 P.M., 12/17/23 at 12:00 A.M. and 6:00 A.M., 12/18/23 at 12:00 A.M. and 6:00 A.M., 12/24/23 at 6:00 A.M., 12/26/23 at 6:00 A.M. and 12/27/23 at 6:00 A.M. The MARS did not have evidence the resident's pain was monitored pre or post administration of the narcotic pain medication. Attempted interview on 12/28/23 at approximately 9:40 A.M. with Resident #51, who was awake and alert, and the resident was not able to appropriately answer questions. Interview on 12/28/23 at 11:15 A.M. with Licensed Practical Nurse (LPN) Wound Nurse #802 indicated the nurse from hospice services monitor Resident #51's pain once weekly and the facility staff did not consistently monitor and assess the resident's pain level as the narcotic pain medications were scheduled and not ordered as needed. LPN Wound Nurse #802 also confirmed Resident #51's MARS revealed no evidence the resident was administered 12 does of the narcotic pain medication from 12/01/23 to 12/28/23. Review of the Pain Assessment and Management policy revised 03/2020 indicated the purposes of the procedure was to help the staff identify pain in the resident, and to develop interventions that were consistent with the resident's goals and needs and that address the underlying causes of pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 7 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement non-pharmacological interventions prior to administering Resident #3 and Resident #53's anti-anxiety medication. This finding affected two (Residents #3 and #53) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including vascular dementia, neuromuscular dysfunction of the bladder and low back pain. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #3's physician orders revealed an order dated 05/06/23 for Lorazepam (anti-anxiety medication) 0.5 mg give one tablet by mouth every four hours as needed for agitation and anxiety. Review of Resident #3's medication administration records (MARS) from 12/01/23 to 12/28/23 revealed the resident received the as needed anti-anxiety medication on 12/1/23 at 1:05 P.M., 12/01/23 at 5:24 P.M., 12/13/23 at 9:27 A.M., 12/19/23 at 1:36 P.M., 12/22/23 at 9:11 P.M., and 12/23/23 at 4:38 A.M. Review of Resident #3's medical record and progress notes from 12/01/23 to 12/28/23 did not reveal evidence the resident was provided non-pharmacological interventions were provided to the resident prior to administering the anti-anxiety medication. Interview on 12/29/23 at 8:20 A.M. with Licensed Practical Nurse (LPN) Wound Nurse #802 confirmed Resident #3's medical record did not have evidence non-pharmacological interventions were implemented prior to administering the anti-anxiety medication.2. Review of Resident #53's medical record revealed the resident was admitted on [DATE] readmitted on [DATE] with diagnoses included but not limited to dementia, chronic obstructive pulmonary disease, and anxiety disorder. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #53's physician orders revealed an order dated 05/06/23 for Lorazepam (anti-anxiety medication) 0.5 mg give one tablet by mouth every twenty-four hours as needed for anxiety. Review of Resident #53's medication administration records (MARS) from 12/01/23 to 12/28/23 revealed the resident received the as needed anti-anxiety medication on 12/20/23 at 9:28 A.M. Review of Resident #53's medical record and progress notes from 12/01/23 to 12/28/23 did not reveal evidence the resident was provided non-pharmacological interventions were provided to the resident prior to administering the anti-anxiety medication. Interview on 12/29/23 at 11:28 A.M. with the Administrator confirmed Resident #53's medical record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 8 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete did not have evidence non-pharmacological interventions were implemented prior to administering the anti-anxiety medication. Review of the Psychotropic Medication Use policy revised 07/22 revealed non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Event ID: Facility ID: 366392 If continuation sheet Page 9 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0759 Ensure medication error rates are not 5 percent or greater. 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 and interview, the facility failed to ensure a medication error rate of less than 5% (percent). Twenty-five medications were observed with two errors for a medication error rate of 8%. This finding affected one (Resident #53) of four residents observed for medication administration. Residents Affected - Few Findings include: Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia and primary generalized osteoarthritis. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #53's physician orders revealed an order dated an order dated 08/04/22 to give one scoop of fiber powder by mouth one time a day for diarrhea; an order dated 08/23/22 for Brimonidine Tartrate solution 0.2% (percent) instill one drop in the left eye two times a day related to unspecified glaucoma and an order dated 12/13/22 for a regular diet, regular texture with a nectar consistency. Observation on 12/28/23 at 7:33 A.M. with Registered Nurse (RN) #809 of Resident #53's morning medication administration revealed ten medications were administered with two errors. The facility administered the Brimonidine eye drop in both eyes and the order was for the left eye. The nurse also administered the fiber powder in water and the resident was on nectar thickened liquids. Interview on 12/28/23 at 8:02 A.M. with RN #809 confirmed Resident #53's eye drops were administered to both eyes in error and the fiber powder was mixed with thin water instead of nectar thickened water as required. Twenty-five medications were observed with two errors for a medication error rate of 8%. Review of the Medication Administration policy revised 11/22 indicated a medication administration record is used to document all medications administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 10 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to ensure accurate serving sizes were served for the pureed meal. This affected two residents (#3 and #39) but had the potential to affect all 10 residents (#1, #3, #9, #12, #19, #23, #36, #39, #47, and #55) residents who received pureed diet. The facility census was 66. Finding included: Review of menu and menu spreadsheet dated 12/28/23 revealed for the pureed meal was #6 scoop serving for the pureed beef stew, #16 scoop serving for the pureed green beans, and #30 scoop serving for the pureed biscuit. Observation on 12/28/23 at 11:44 A.M. of tray line service revealed grey handled scoops placed in each of the pureed beef stew, pureed green beans, and pureed biscuits. Observed at 11:57 A.M. of [NAME] #885 prepare a pureed meal using the gray handled scoop for each pureed item, one serving each, and placed on the tray on the second meal cart for hall trays. Observed at 12:04 P.M. [NAME] #885 prepare another pureed meal using the gray handled scoop for each pureed item, one serving each, and placed on tray on the third/last meal cart for hall trays. Interview on 12/28/23 at 12:05 P.M. with [NAME] #885 verified the gray handled scoops were #8 scoops used to serve the pureed meals and were not correct serving utensils according to the menu spreadsheet. Review of the facility list of resident diets revealed Resident #1, #3, #9, #12, #19, #23, #36, #39, #47, and #55 received pureed foods. Review of the Portion Control Chart posted on the reach in refrigerator across from the steam table next to the ice machine revealed a color coded scoop chart. The chart indicated the #8 scoop was a gray handled scoop and provided four ounce servings. The #6 scoop was a white handle scoop that provided five and one third ounce serving and should had been used for the pureed beef stew; the #30 scoop was a black handled scoop that provided one ounce serving and should had been used to serve the pureed biscuit; and the #16 scoop was a blue handled scoop that provided two ounce serving. Review of the facility policy titled Kitchen Weights and Measures, revised April 2007 revealed food service staff will be trained in proper use of cooking and serving measurements to maintain portion control. Recipes will specify consistent use of metric or U.S. measurement guidelines. Serving utensils used will be consistent with choice of metric or U.S. measure used. Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators (e.g., color coded) on utensils will be prominently displayed for reference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 11 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure cold, perishable food (milk) was maintained a proper temperatures. This had the potential to affect all 66 residents in the facility. Residents Affected - Many Findings include: Interviews on 12/27/23 between 9:28 A.M. and 11:01 A.M. with Residents #34, #42, and #66 complained of the food temperatures of the meals when they received them in their rooms. Observation on 12/28/23 at 11:44 A.M. of tray line services for halls trays revealed three silver, open meal carts set up with meal trays that had pre-poured beverages including milk. Observation on 12/28/23 at 12:38 P.M. of the last tray served for the hall meal trays. At this time the test tray was preformed and revealed the beef stew and green beans very warm to hot and tasted very good. The pre -poured glass of milk tempted at 55 degrees Fahrenheit. Interview at this time with Dietary Manager (DM) #836 stated the milk should be colder. Reviewed policy Food Preparation and Service revised November 2022 revealed food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Under food preparation, cooking, and holding time/temperature revealed the danger zone for food temperatures is above 41 degrees Fahrenheit and below 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. Therefore, PHF must be maintained at or below 41 degrees Fahrenheit or at or above 135 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 12 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interviews, the facility failed to maintain a clean and sanitary nursing unit refrigerator and failed to ensure milk was stored safely to maintain proper temperature during meal service. This had the potential to affect all 66 residents. Findings include: 1. Observation on 12/28/23 between 8:16 A.M. and 8:28 A.M. of the nursing unit refrigerator on the 700 and 800 hall revealed in the freezer a large brownish frozen food splatter and in the refrigerator various food splatter and a black residue on the inside back wall. Interview at this time with Dietary Manager (DM) #836 verified the observations. 2. Observation on 12/28/23 at 8:38 A.M. of Registered Dietitian (RD) #805 passing breakfast trays on the 500 hall. Observed on the beverage care a gallon of opened milk sitting out on the cart. Interview at this time with RD #805 verified the observation and stated they take the milk out of the refrigerator on unit and it was usually out for about hour while meal trays were being passed. RD #805 stated then the milk was put right back into the refrigerator after the trays were passed. Observation on 12/28/23 at approximately 8:40 A.M. of State Tested Nurse Aide (STNA) #823 passing breakfast trays on the 800 hall and observed a gallon of opened milk sitting out on the beverage cart. Interview at this time with STNA #823 verified the observation and stated that was normal practice. Observation on 12/28/23 at 11:44 A.M. of tray line services for halls trays revealed three silver, open meal carts set up with meal trays that had pre-poured beverages including milk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 13 of 14 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 366392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to ensure basic infection control practices were maintained related to catheter bag placement for Resident #5. This affected one resident (Resident #5) of one resident reviewed for catheter care. The facility census was 67. Residents Affected - Few Findings Include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dementia and neuromuscular dysfunction of the bladder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact, required extensive assistance of one staff person for completing her activities of daily living and the use of indwelling foley catheter to empty her bladder. Observation of Resident #5 on 12/27/23 at 10:29 A.M. revealed Resident #5 was up and sitting in her recliner. Resident #5's foley catheter bag was uncovered, touching the floor and hanging on a trash can next to the recliner with trash inside the can. Interview at this time with Licensed Practical Nurse (LPN) #811 verified Resident #5's foley catheter bag was uncovered, touching the floor and hanging on a trash can next to the recliner with trash inside the can. Interview with Resident #5 on 12/27/23 at 10:33 A.M. revealed facility staff hangs the catheter bag from the trash can all the time. Review of the policy titled, Catheter care, Urinary Policy, dated 08/01/22, revealed staff should observe tubing and drainage bag to prevent contact with the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366392 If continuation sheet Page 14 of 14