Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review, and policy review, the facility failed to ensure respiratory equipment
was maintained in a sanitary manner. This affected one resident (Resident #65) of two residents reviewed
for respiratory care.
Residents Affected - Few
Findings include:
Review of Resident #65's medical record revealed an original admission date of 06/18/21 and diagnoses
including chronic obstructive pulmonary disease (COPD), moderate protein-calorie malnutrition,
depression, anxiety disorder, anemia, chronic respiratory failure and hypertension (high blood pressure).
Review of census data revealed Resident #65 was on hospice care as of 08/20/21 and showed admissions
to the facility from 06/18/21 to 07/11/21, from 07/26/21 to 08/14/21, from 08/20/21 to 12/04/21 and from
12/13/21 to present.
Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #65 was
cognitively intact and required supervision for bed mobility, eating and ambulation off of the unit. Resident
#65 did not have upper or lower extremity impairment. Resident #65 was coded as using oxygen and
non-invasive mechanical ventilator and was under hospice care.
Review of Resident #65's physician's orders revealed an order dated 06/20/21 for change aerosol tubing
and set up and clean filter every week per facility policy every night shift every Sunday for oxygen care; an
order dated 06/20/21 for change oxygen tubing with oxygen ears and/or set up and clean filter each week
per policy every night shift every Sunday for oxygen care; an order dated 08/20/21 for ipratropium-albuterol
solution 0.5-2.5 (3) milligrams/three milliliters, three milliliters inhale orally four times a day for shortness of
breath; an order dated 08/20/21 for place on Bilevel Positive Airway Pressure (BiPAP) before bed and
remove in the morning every evening shift for COPD; an order dated 08/20/21 for oxygen at two to 10 liters
via nasal cannula continuous to maintain oxygen saturation at or above 92% every shift for COPD; and an
order dated 08/21/21 for place on BiPAP before bed and remove in the morning every day shift for COPD.
Orders did not address cleaning the BiPAP.
Observation on 01/10/22 at 1:33 P.M. of Resident #65's room revealed Resident #65 was laying in bed and
an oxygen machine was to the left of the bed with green tubing from the machine to a nasal cannula. No
date was noted on the oxygen tubing. A nebulizer with mask attachment was on Resident #65's nightstand
open to air and the mask had a date of 12/03/21. A Bilevel Positive Airway Pressure (BiPAP) machine was
also on Resident #65's nightstand open to air and was not dated.
(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 8
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
01/20/2022
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 01/10/22 at 1:33 P.M. with Resident #65 revealed he was not sure how often the oxygen tubing
was changed but indicated he had never seen the nebulizer or the BiPAP machine cleaned.
Observation and interview on 01/10/22 at 1:56 P.M. with the Director of Nursing (DON) verified Resident
#65's nebulizer mask was dated 12/03/21 and was open to air; the DON indicated indicated nebulizers
were typically changed out weekly on Sundays. The DON verified the BiPAP and the oxygen tubing were
not dated and stated they should have been per policy. The DON stated Resident #65 used hospice
services and they often provided his respiratory supplies. No evidence was available to determine when the
BiPAP had been last cleaned.
Review of the facility's policy on CPAP/BiPAP Support, revised December 2017 revealed these were
general guidelines for cleaning, as specific guidelines were obtained from the manufacturer of the PAP
device. PAP machines were to be wiped with warm, soapy water and rinsed at least once a week and as
needed.
Review of the facility policy, Care and Maintenance of Oxygen Concentrators, dated February 1999
revealed change humidifier and cannula once per week. Label with date of change.
Review of policy, Hand Held Nebulization, revised July 2005, revealed after each treatment, rinse
mouthpiece and chamber under warm running water and allow to air dry. Each resident receiving hand held
nebulizations should be issued a new medication nebulizer weekly. Discard old nebulizer and storage bag.
Assemble new nebulizer and place in set-up bag provided. Always mark bag with resident's name and date
changed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366392
If continuation sheet
Page 2 of 8
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
01/20/2022
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, interview, review of a test tray, review of resident council minutes, diet list review and
recipe review, the facility failed to ensure foods were served at safe and palatable temperatures and failed
to ensure pureed items were prepared appropriately. This affected 66 of 67 residents residing in the facility
as Resident #43 received nothing by mouth (NPO).
Residents Affected - Many
Findings include:
1. Interviews on 01/10/22 from 10:36 A.M. to 5:08 P.M. and on 01/11/22 at 10:45 A.M. with Residents #10,
#16, #27, #32, #34, #46, #51 and #68 indicated concerns regarding food being served cold and food not
being palatable.
Observation on 01/12/22 starting at 11:30 A.M. revealed [NAME] #317 tested temperatures of the meal to
be served using the facility's self-calibrating thermometer. Temperatures were as follows: carrots 160
degrees Fahrenheit (F); ham, 191 degrees F; oven roasted potatoes, 165 degrees F; alternate meal of
stuffed pepper casserole, 196 degrees F; fruited jello, 38 degrees F. Lunch service started at 11:37 A.M.
Five meal carts were observed to be used for meal service across the building and all residents were
receiving meals in styrofoam due to the facility's COVID-19 outbreak. A test tray was requested for the 600
hall. The test tray was assembled at 12:07 P.M., was on the meal cart at 12:07 P.M. and the cart left the
kitchen at 12:08 P.M. The meal cart arrived on the unit at 12:08 P.M. and tray pass began at 12:13 P.M. The
tray was sampled at 12:32 P.M. with Food Service Director (FSD) #301 and one other surveyor.
Temperatures of the foods to be sampled were obtained with the facility's self-calibrating thermometer and
were as follows: potatoes, 106 degrees F; carrots, 100.8 degrees F; ham, 118 degrees F; juice, 51 degrees
F; applesauce, 46.5 degrees F. The hot food items were lukewarm and did not taste palatable.
Interview on 01/12/22 at 12:32 P.M. with FSD #301 indicated the minimum hot serving temperature was
whatever satisfied the residents. FSD #301 verified she and Registered Dietitian (RD) #323 did not do test
trays to test food quality and temperatures.
Interview on 01/12/22 at 12:51 P.M. with the Administrator and Previous Administrator (PA) #413 revealed
the facility was using styrofoam instead of plates for all residents in efforts to stop the spread of COVID-19;
food palatability was important but COVID-19 was more important. The Administrator and PA #413 were
made aware of the temperature concerns identified during the test tray with FSD #301 during the interview.
Review of resident council minutes revealed on-going concerns with food, including food is still cold (March
2021); residents planning on contacting health department on quality of food because nothing is being
done (June 2021); food is still cold (June 2021); food is cold sometimes (October 2021); food is cold and not
getting passed out quickly enough (November 2021). Review of related Administrator's response sheets did
not address food temperatures.
Review of a facility diet list dated 01/10/22 revealed Resident #43 received nothing by mouth (NPO).
No policy specifying minimum food temperatures at point of service was provided for surveyor review.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366392
If continuation sheet
Page 3 of 8
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
01/20/2022
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
2. Observation on 01/11/22 from 9:34 A.M. to 9:51 A.M. revealed [NAME] #317 was preparing a meal of
pureed stuffed pepper casserole. [NAME] #317 indicated she was going to make five pureed portions as
she needed five portions. [NAME] #317 pulled a 1/6th pan from the oven that had casserole inside and
stated the size of pan gave enough food for five people. The surveyor inquired about what recipe she was
using as no recipes were present on the prep table where the food processor was. [NAME] #317 had a
measuring cup with between one and 1.5 cups of water in it and was pouring water (undetermined amount)
into the food processor to obtain a mashed potato consistency with the stuffed pepper casserole. Interview
with [NAME] #317 indicated at times she would use gravy instead of water to thin a pureed item as needed.
The item was blended and placed in a pan for hot holding prior to service.
Interview on 01/11/22 at 9:37 AM. with FSD #301 revealed there was no recipe available for pureed stuffed
pepper casserole for review at the time of observation. FSD #301 was questioned why water was added to
thin the puree and FSD #301 stated she had never worked anywhere where they didn't thin the purees with
water.
Interview on 01/11/22 at 9:51 A.M. with RD #323 and FSD #301 revealed the recipe for pureed stuffed
pepper casserole was not in the current menu cycle book because the book had not yet been updated.
Interview on 01/11/22 at 10:53 A.M. with RD #323 and FSD #301 revealed a recipe for pureed stuffed
pepper casserole was provided and it did not direct staff to add any liquids at all. When asked again if it was
appropriate to add water to pureed foods as a thinning agent, FSD #301 stated they do all of the time, that's
what [pureed food] is.
Review of a recipe for Green Pepper Stuffed Pureed Thick, no date, listed ingredients as stuffed green
pepper and food thickener. No liquids were listed as an ingredient. Steps included:
1. Prepare stuffed peppers as directed
2. Remove portions to be pureed from the regular prepared entrée. One portion equals one pepper
plus 2.5 ounces sauce. Set sauce aside.
3. Place stuffed peppers in food processor and process to fine consistency.
4. Add food thickener and sauce to stuffed peppers while processing.
5. Scrape down sides of processor with a rubber spatula and process for 30 seconds.
6. Serve with #6-scoop.
Review of a facility diet list dated 01/10/22 revealed five residents received pureed meals, Residents #2,
#44, #45, #50 and #59.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366392
If continuation sheet
Page 4 of 8
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
01/20/2022
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 0810
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure Resident #44's assistive device for
drinking was in place as ordered. This affected one resident (Resident #44) out of four residents reviewed
for adaptive equipment.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #44 revealed an admission date of 05/31/19. Diagnoses included
Alzheimer's disease, dysphagia oropharyngeal, insomnia, delusional disorder, anxiety disorder, psychotic
disorder, and major depressive disorder.
Review of Resident #44's care plan, dated 06/03/19, revealed episodes of nutritional problems, abdominal
pain, indigestion, nausea/vomiting, diarrhea, constipation, and dysphagia related to gastroesophageal
reflux disease and irritable bowel syndrome. Interventions include diet per registered dietician (RDLD)
recommendations and physician orders. Altered nutritional status was evidenced by inadequate intake,
underweight Body Mass Index less than 19, difficulty chewing/swallowing, required feeding assistance, diet
modified consistencies, and supplements. Interventions also included adaptive equipment as ordered.
Review of Resident #44's Nutritional Assessment, dated 10/23/21, revealed recommendation of a low
fat/low cholesterol pureed diet, nectar thick liquid diet with feed assist sippy cup with meals. Staff were to
continue feeding assistance for Resident #44.
Review of Resident #44's speech therapy discharge note, dated 11/24/21, revealed resident and caregiver
training provided was provided and included use of swallow strategies of alteration of liquids and solids,
small sips/bites, and upright positioning during intake, and use of nosey cup.
Review of Resident #44's quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed
Resident #44 had impaired cognition, and was total dependent for all activities of daily living (ADLs).
Review of Resident #44's physician orders for January 2022 revealed orders for swallow strategies nosey
cup with liquids. This adaptive equipment was initiated on 04/03/20.
Interview and observation on 01/11/22 at 12:15 P.M. with Licensed Practical Nurse (LPN) #308 revealed
Resident #44 was not using her nosey cup and her liquids were served in a Styrofoam cup.
Interview on 01/11/22 at 2:45 P.M. with LPN #308 revealed if a resident needed adaptive equipment no
matter what their COVID-19 status was, the staff were to go to the kitchen and get the proper adaptive
equipment.
Review of the facility policy titled, JAG-Assistance with Meals, revealed adaptive devices would be provided
for residents who need to request them. These may include devices such as silverware with
enlarged/paddle handles, plate guards, and/or specialized cups.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366392
If continuation sheet
Page 5 of 8
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
01/20/2022
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** 3.
Observation of lunch tray pass on 01/10/22 starting at 11:59 A.M. on the 700 hall revealed an isolation
gown hanging on a light fixture with a second isolation gown balled up and stuck inside the handrail outside
of room [ROOM NUMBER].
Residents Affected - Many
Interview on 01/10/22 at 12:11 P.M. with Director of Nursing (DON) revealed the facility was not reusing
gowns. During the interview, DON asked State Tested Nursing Assistant (STNA) #342 about the gowns and
STNA #342 stated they had been there since last night (01/09/22).
4. Observation of the 700 hall on 01/10/22 starting at 4:44 P.M. revealed Environmental Aide (EA) #372
entered room [ROOM NUMBER] with bedpads in hand and had complete personal protective equipment
(PPE) on, including an isolation gown. EA #372 left room [ROOM NUMBER] with the isolation gown still on
and stood in the hallway before entering room [ROOM NUMBER].
Interview on 01/10/22 at 4:46 P.M. with EA #372 verified she did not take off (doff) her isolation gown
between rooms. EA #372 stated she was only going to rooms that had residents positive for COVID-19 and
did not know she had to take off isolation gowns in between rooms.
Interview on 01/10/22 at 5:26 P.M. with Administrator and the DON revealed EA #372 should have doffed
her gown in between resident rooms as there was no zipper barrier on the 700 unit for COVID-19 positive
residents. Isolation gowns were not to be worn room to room.
Review of policy, Standard Precautions, revised February 2018, revealed staff should remove a soiled gown
as promptly as possible and wash hands to avoid transfer of microorganisms to other residents or
environments. Staff should remove gown and perform hand hygiene before leaving the resident's room.
Based on record review, staff interview, observation, and review of facility policy, the facility failed to ensure
staff screened for COVID-19 signs and symptoms prior to working, failed to ensure proper use and disposal
of personal protective equipment (PPE) was in place. This had the potential to affect all 67 residents in the
facility.
Findings included:
1. Review of the facility COVID-19 testing revealed State Tested Nursing Assistant (STNA) #349 tested
positive on 01/11/21, STNA #390 tested positive on 01/10/22, and Therapy assistant #396 tested positive
on 01/10/22.
Review of the screening logs and time punches for three staff, STNA #349, STNA #390 and Therapy
Assistant # 397 revealed the following:
STNA #349 worked on 01/01/22 from 6:17 A.M. through 3:12 P.M., 01/02/22 from 6:19 A.M. through 7:06
P.M., 01/03/22 from 6:03 A.M. through 3:01 P.M., 01/05/22 from 2:18 A.M. through 3:33 P.M., 01/06/22 6:13
A.M. through 3:23 P.M., 01/07/22 from 6:06 A.M. through 3:10 P.M., 01/08/22 from 2:21 A.M. through 3:00
A.M., 01/11/22 from 2:30 A.M. through 7:00 A.M., and 01/13/22 from 6:22 A.M. through unknown time. No
screenings were completed by STNA #349 for these days worked.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366392
If continuation sheet
Page 6 of 8
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
01/20/2022
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
Level of Harm - Minimal harm
or potential for actual harm
STNA #390 worked 01/01/22 2:00 P.M. through 4:01 A.M., 01/02/22 from 2:09 P.M. through 7:05 A.M.,
01/03/22 from 3:12 P.M. through 12:06 A.M., 01/04/22 from 6:22 P.M. through 1:11 A.M., 01/05/22 from
2:08 P.M. through 11:57 P.M., 01/06/22 from 2:24 P.M. through 12:00 A.M., 01/07/22 from 2:09 P.M. through
11:00 P.M., and 01/10/22 from 2:07 P.M. through 3:00 P.M. No screening was completed by STNA #390 for
these days worked.
Residents Affected - Many
Therapy Assistant #397 worked 01/03/22 8:56 A.M. through 2:25 P.M., 01/04/22 from 7:30 A.M. through
3:00 P.M., 01/05/22 from 8:30 A.M. through 4:30 P.M., 01/06/22 from 6:30 A.M. through 2:22 P.M. No
screening was completed by the Therapy Assistant #397 on these days.
Interview on 01/13/22 at 12:50 A.M. with Director of Nursing and Administrator revealed they had 22
residents and 19 staff test positive for COVID-19 since 01/01/22. Currently the facility had 16 positive
residents and seven staff.
Interview on 01/13/22 at 1:15 P.M. with Administrator verified Therapy Assistant #397, STNA # 349 and
#390 did not complete self-screening form 01/01/22 through 01/13/22 before working the floor.
Interview on 01/13/22 at 3:45 P.M. with Receptionist #314 revealed she comes in at 8:30 A.M. and leaves at
5:30 P.M. Staff were to come in and out the back door. When she comes in, in the mornings she collected
the screening forms from the back entrance and placed them in a folder. She did not review the screening
sheets.
Phone interview on 01/13/22 at 4:16 P.M. with Therapy Assistant #397 revealed they were supposed to
screen, and she sometimes forgot. She would come in the back door by our parking, walk to the break
room screen and clock in. She was not aware if anyone was monitoring the screening logs.
Interview on 01/19/22 at 9:50 A.M. with Administrator revealed if staff had symptoms, they would
communicate this through text or phone calls to their supervisor. The supervisor would make the call if the
staff was to stay or go home. Administrator revealed there was not a process in reviewing screening logs.
Review of staff training dated 01/05/21 revealed staff were educated on wearing N-95 masks, eye
protections and screening upon arrival.
Review of the facility policy titled, COVID Testing/Surveillance/Screening, revealed upon arrival to work
employees will screen using then provided screening tool with COVID surveillance questions. Employees
will also obtain with temperature upon arrival to ensure it was not 100.0 degrees of higher. Should an
employee say yes to a screening question or have an elevated temperature, they were instructed to contact
their direct supervisor, nurse in charge, and /or administration immediately to get further direction.
Employees will either be restricted from further entry, be COVID tested, be permitted to work should the
nurse/administrator determine that their level of exposure does not meet the criteria to be excluded from
work. Current state and federal guidelines will be considered when deciding the course of action to take
following screening tool being triggered.
2. Interview and observation on 01/11/22 at 11:10 A.M. with STNA #309 revealed she was wearing a
surgical mask under her N-95 mask and going into COVID-19 positive rooms. She verified she was
supposed to wear the surgical mask over the N-95 mask and was wearing it improperly. She further verified
she was trained on how to wear the masks properly.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366392
If continuation sheet
Page 7 of 8
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
01/20/2022
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Interview and observation on 01/11/22 at 12:25 P.M. with Care Manager #335 revealed she was wearing a
surgical mask under her N-95 masks on the 400 hallway. She revealed she was trained on the proper way
to wear masks.
Review of the facility policy, Personal Protective Equipment, revised January 2018, revealed staff required
to perform tasks that may involve exposure to blood/bodily fluids will be provided appropriate protective
clothing and equipment. Type of protective clothing would depend on likelihood of exposure, probable route
of exposure and working conditions. The policy did not address COVID-19 specifically.
Review of the facility policy titled, JAG-Monitoring Compliance with Infection Control, revealed the infection
preventionist or designee shall monitor the effectiveness of infection prevention and control work practices
and protective equipment. this includes, but was not necessarily limited to: Surveillance of the workplace to
ensure that established infection prevention and control practices were observed, and protective clothing
and equipment were provided and properly used.
Review of staff training dated 01/05/21 revealed staff were educated on wearing N-95 masks, eye
protections and screening upon arrival.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366392
If continuation sheet
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F810 - Assistive devices
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the January 20, 2022 survey of BURBANK PARKE CARE CENTER?
This was a inspection survey of BURBANK PARKE CARE CENTER on January 20, 2022. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BURBANK PARKE CARE CENTER on January 20, 2022?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.