F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to accurately document the intakes of nutritional
supplements as ordered by the physician for four of four residents reviewed for nutrition (Resident #10,
Resident #22, Resident #40 and Resident #55). The facility census was 69.
Findings include:
1. Resident #22 was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition,
dementia and abnormal weight loss. The care plan dated 08/23/19 indicated the resident was at risk for
weight loss. She had a physician's order dated 07/26/19 for nutritious juice twice a day with breakfast and
lunch and a physician's order dated 07/29/19 for six ounces of a liquid nutritional supplement with supper.
Review of documentation for the intakes of the supplements from 08/20/19 through 09/17/19 revealed the
supplements were only documented for two meals on 08/20/19, 08/22/19, 08/23/19, 08/24/19, 08/29/19,
08/31/19, 09/01/19, 09/02/19, 09/03/19, 09/08/19, 9/10/19, 09/11/19, 09/14/19, 09/15/19 and 09/17/19 and
for only one meal on 09/09/19. This concern was verified with Registered Dietician/Licensed Dietician
(RDLD) #100 on 09/18/19 at 12:35 P.M.
2. Resident #10 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral
disturbance, Alzheimer's disease and epigastric pain. The care plan dated 06/20/19 indicated the resident
was at risk for weight loss. Dietary notes dated 08/16/19 indicated the resident had a significant weight loss
of 4.64 percent for one month and had variable meal intakes. The resident had a physician order dated
08/29/19 for six ounces of a nutritional supplement with lunch and dinner.
Review of documentation for the intakes of the supplement from 09/01/19 through 09/17/19 revealed the
supplements were only documented one time on 09/02/19, 09/04/19, 09/05/19, 09/06/19, 09/08/19,
09/10/19, 09/11/19, 09/12/19 and 09/17/19 and were not documented at all on 09/01/19, 09/03/19,
09/07/19, 09/13/19, 09/14/19 and 09/15/19. This concern was verified with RDLD #100 on 09/18/19 at
12:40 P.M.
3. Record review for Resident #40 revealed she was admitted to facility on 01/10/11 with diagnoses
including stroke, dysphagia (trouble swallowing), pain, pneumonia, gastrostomy (a tube inserted through
the abdominal wall into the stomach for nutrition/medication), anemia, and gastroesophageal reflux disease
(GERD).
Physician orders for Resident #40 include: House supplement in the afternoon, six ounces (oz) with
(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:
366092
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
366092
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Burton Health Care Center
14095 E Center St
Burton, OH 44021
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
lunch. State Tested Nursing Assistants (STNAs) to record percentage consumed in plan of care (POC) with
meal documentation. This start date of this order was 07/27/19.
Observation on 09/18/19 at 12:09 P.M. during tray line service revealed the house supplement being placed
on the lunch tray for Resident #40. The staff who delivered the tray, opened and poured the contents into a
cup. The house supplement was delivered to her.
Observation on 09/19/19 at 12:28 PM revealed Resident #40 in the dining room. She had a cup on her tray
with the house supplement, some of which had been consumed.
Review of nutrition tracking for Resident #40, from 08/20/19 through 09/17/19, revealed the house
supplement was not offered on six days; 08/23/19, 08/25/19, 08/31/19, 09/01/19, 09/08/19, and 09/16/19.
Interview on 09/19/19 at 12:35 P.M. with Registered Nurse (RN) #105 confirmed Resident #40 was
documented as not receiving the supplements. He confirmed the kitchen rarely runs out of nutritional
supplements and there is always an alternative to be given.
4. Clinical record review for Resident #55 revealed she was admitted to facility on 12/10/18 with diagnoses
including failure to thrive, moderate protein calorie malnutrition, GERD, pneumonia, and salivary gland
cancer.
Physician orders for Resident #55 include: Nutritious juice with meals, six oz with breakfast, lunch, and
dinner. STNAs were to record percentage consumed in the plan of care (POC) with meal documentation.
The start date was 05/30/19.
Observation on 09/18/19 at 12:35 P.M. during tray line service revealed the nutritious juice was placed on
the lunch tray for Resident #55.
Observation on 09/19/19 at 12:54 P.M. revealed Resident #55 in her room during lunch. She had a full cup
on her tray with the nutritious juice. None had been consumed.
Review of nutrition tracking for Resident #55, from 08/20/19 through 09/17/19, revealed the nutritious juice
was not offered one of three times for eight days; 08/25/19, 08/26/19, 08/27/19, 09/03/19, 09/06/19,
09/07/19, 09/13/19, and 09/15/19. It was not offered for two of three times for four days; 08/20/19, 09/01/19,
09/14/19, and 09/16/19.
Interview on 09/19/19 at 12:35 P.M. with RN #105 confirmed Resident #55's supplements were not
documented as provided. He confirmed the kitchen rarely runs out of nutritional supplements and there is
always an alternative to be given.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366092
If continuation sheet
Page 2 of 2
