Inspection·December 27, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident and staff interview, record review, and policy review, the facility failed to provide routine bathing and grooming services for Resident #65 and routine bathing services for Resident #63. This affected two residents (#65 and #63) of three residents reviewed for provision of Activities of Daily Living (ADLs). The facility census was 74. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #65 revealed an admission date of 11/03/23. Medical diagnoses included wedge compression fracture of the vertebrae, muscle weakness, chronic pain, and a myocardial infarction (heart attack). Resident #65's listed shower days were on Mondays and Fridays. Review of Resident #65's admission Minimum Data Set (MDS) assessment, dated 11/09/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Resident #65 was identified to be hard of hearing but did not use a hearing aide. Resident #65 required substantial/maximum assistance with toileting, showering/bathing, and dressing. Resident #65 was dependent for personal hygiene tasks, which included shaving. Review of Resident #65's care plan, revised 12/12/23, revealed Resident #65 required assistance with ADL performance and required one staff member for assistance in completing ADLs, including bathing and personal hygiene tasks. Review of Resident #65's shower documentation revealed only one day, 12/18/23, on which a skin check shower sheet was completed by the State Tested Nursing Assistant (STNA). The form noted Resident #65 refused a shower but allowed a bed bath. The sheet made no mention of whether or not shaving was completed. A separate entry of documentation of Resident #65's ability to shower and bathe self in the electronic medical record identified another date, 12/26/23, on which Resident #65 was showered. There was no corresponding skin check sheet completed by the STNA for 12/26/23. There were no other documents to show additional showers/bathing was completed. An observation on 12/27/23 at 8:01 A.M. of Resident #65 revealed the resident in the bed with facial hair to cheek, chin, and moustache approximately one quarter inch in length. Resident #65 stated he preferred to be clean shaven and he was past due for a shave. Resident #65 estimated it had been approximately one week since he had last received a shower. An interview on 12/27/23 at 8:03 A.M. with Licensed Practical Nurse (LPN) #102 verified Resident #65 was unshaven and stated staff had not yet gotten to him. LPN #102 stated he would be clean shaven in a bit. (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: 365837 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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)