Health inspection·February 7, 2019

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to provide consistent mouth care to Resident #24 who was dependent on staff for activities of daily living. This affected one of four residents (#7, #15, #24, #31) reviewed for activities of daily living and one of six residents (#12, #15, #22, #24, #51 and #62) who [NAME] tube feedings. Residents Affected - Few Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, heart failure, cerebral infarction, acute respiratory failure, muscle weakness, dysphagia, speech disturbance and tracheostomy. Review of the physician orders indicated she could not take food by mouth and received nutrition via feeding tube. Review of the admission comprehensive assessment (MDS 3.0) dated 06/29/18 indicated she was severely cognitively impaired, did not display behaviors and required the extensive assistance of one staff for personal hygiene. She was noted to have obvious or likely cavities or broken natural teeth. Review of the activity of daily living plan of care initiated on 06/25/18 indicated staff were to assist the resident with oral care. Review of the oral health problem care plan initiated on 06/25/18 revealed interventions to assess oral cavity for pain, sensitivity, presence of lesions, ulcers, inflammation, bleeding, swelling or rashes, assess/provide mouth care as needed, dietitian to assess, referral to dental services, use mouth rinse every 12 hours as needed. Review of the task section of the electronic medical record where STNAs charted provision of care indicated mouth care was marked as provided on 27 out of the last 30 days. Review of a dental service visit dated 08/23/18 indicated Resident #24 had heavy plaque and calculus on her teeth. Her oral hygiene status was poor. Observation of Resident #24 on 02/04/19 at 10:00 A.M., on 02/05/19 at 9:24 A.M., 3:52 P.M. and on 02/06/19 at 8:40 A.M. and at 9:30 A.M. revealed a thick layer of hard, dried crusty film across her lips. On 02/06/19 at 9:33 A.M. State Tested Nurse Aide (STNA) #96 verified the resident's mouth was in need of care. She washed her hands, applied disposable gloves, obtained wash cloths, wet them with warm water and began to gently soak and wipe Resident #24's mouth. The thick layer of hard, dried crust was removed. She used a toothette to swab the interior of her mouth. Afterwards, STNA #96 applied (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: 366403 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 366403 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bath Creek Estates 186 West Bath Road Cuyahoga Falls, OH 44223 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)