Inspection·February 28, 2019

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] diagnoses including non-traumatic intracerebral hemorrhage, hemiplegia and hemiparesis, muscle weakness, major depressive disorder, and dysphagia. The comprehensive MDS 3.0 assessment, dated 01/10/19, indicated the resident had natural teeth or fragments. Residents Affected - Few Documentation on the Nursing Assessment, dated 01/05/19, under the oral status section, it was documented that the resident had no dental issues and the areas of dentures and edentulous were left blank. Interview on 02/25/19 at 9:13 A.M. with the resident revealed she had a stroke about four months ago and she had not worn her dentures during that time. She stated her gums have changed and the dentures did not fit anymore. She did indicate her husband brought in denture adhesive, and that helped a little. She stated she needed to see a dentist and have her dentures relined. Observation of the resident revealed she was edentulous, and there was a denture cup on the overbed table. Observation and interview on 02/26/19 at 5:23 P.M. with the resident revealed a dinner tray with 5% of the meal eaten. The meal was a mechanical soft diet. The resident stated that she could not chew the food and had to spit it out. She then began to cry. The resident was hoping for an upgrade of her diet so she could be discharged home. The resident stated she has had the same dentures since she was in her 20's and she was now 65 and hasn't had a problem until now. Interview 02/27/19 at 10:23 A.M. with the Dietitian she stated the resident was one of her tough residents. She stated yesterday when the Speech Therapist got a mechanical tray for her, and the resident would spit out the food indicating she could not swallow it. This surveyor asked if she was aware the resident had dentures. She stated yes, that they did not fit properly and that she offered the resident the opportunity to see the dentist but she refused stating she would be going home before he came in. She said the resident stated that she would see her own dentist when she was discharged . She stated the resident was anticipating being discharged on Friday because of her insurance will end on that date. Interview on 02/27/19 with MDS Coordinator, Registered Nurse (RN) #500, verified that the dental information she had gotten for the MDS was from the nursing assessment, and the dental information was incorrect. Based on record review and interview, the facility failed to ensure Residents #20, #49 and #51's comprehensive assessments were complete and accurate. This finding affected three residents (Residents #20, #49 and #51) of twenty-six resident records reviewed for comprehensive assessments. The (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 6 Event ID: 366392 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 02/28/2019 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)