Inspection·January 15, 2020

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement an individualized meal plan to meet Resident #22's needs. This affected one (Resident #22) of eight residents reviewed for nutrition. Residents Affected - Few Findings include: Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Huntington's disease, gastroesophageal reflux disease, dysphagia, anxiety disorder, dementia with behavioral disturbance, mild protein calorie malnutrition, mood disorder, chronic migraines and major depressive disorder. Review of the comprehensive assessment (MDS 3.0) dated 10/03/19 indicated Resident #22 was alert, oriented and independent in daily decision making ability. He had indications of delusions and rejected care on one to three days of the assessment period. He required supervision and setup help only for eating. He was provided a therapeutic diet. Review of the nutrition assessment dated [DATE] indicated Resident #22 had a body mass index of 19. Supplement orders included med pass 120 milliliters (ml) three times daily. The resident's meal intake ranged from 75-100%, with supplement intake of 50-75%. The comments indicated the average intake was 84% with refusal at times. Also noted was a history of the behavior of not eating to get what he wanted. The ideal body weight was 154 pounds. The goal was for gradual weight gain. Review of the dietary assessment narrative dated 01/02/20 at 9:15 P.M. indicated the fortified cereal at breakfast provided 536 calories, 14 grams of protein and the med pass 2.0 provided 720 calories and 30 grams or protein. He was noted to refuse 100%. Review of the nutrition plan of care indicated the interventions included providing the diet per current orders, honor food preferences as able, offer an evening snack, provide adaptive equipment, may have one energy drink every day, recommend diet pop in place of regular if consuming multiple per day, supplements and fortified foods per orders. Review of weights revealed from 06/05/19 to 01/02/20 the resident's weight went from 132 pounds to 125 pounds. A total weight loss of 5.3 percent over a seven month period of time. Review of meal intakes for the last 30 days revealed the resident had one meal during typical breakfast hours on 12/26/19 and missed all three meals on five days (12/19/19, 12/20/19, 12/24/19, 01/06/20 and 01/11/20). Interview with Resident #22 on 01/12/20 at 3:30 P.M. revealed he didn't like the food very much. He had his own whey powder and used it to make his own shakes. He could not say how often he did that. Review of the nutrition assessment revealed it did not take into account his own supplement. Numerous observations of Resident #22 on 01/12/20 at 3:30 P.M. and throughout the survey through 01/15/20 revealed he appeared to be very thin and was in constant motion. Interview with Licensed Practical Nurse (LPN) #465 on 01/13/20 at 3:03 P.M. reported the resident never ate breakfast. Resident #22 said when he ate it slowed him down and he became tired. He would eat double portions of chicken fingers, macaroni and cheese, but absolutely hated turkey. His intake (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365134 If continuation sheet Page 2 of 5 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 365134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Ridge Nursing & Rehabilitation Center 721 Hickory St Akron, OH 44303 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 0684 of ordered supplements was hit or miss. Level of Harm - Minimal harm or potential for actual harm Interview with Dietary Manager #427 on 01/13/20 at 2:34 P.M. revealed Resident #22 ate pretty well occasionally. She reported his mother brought food in for him. The resident was changed from a regular supplement to a very high calorie supplement on 01/02/20 to increase calories. Dietary Manager #427 was aware of his occasional use of the whey supplement but could not count it because it was so sporadic. Residents Affected - Few Interview with State Tested Nurse Aide (STNA) #527 on 01/14/20 at 2:05 P.M. revealed the resident always refused breakfast because he did not get up until after noon, and sometimes refused lunch. He would have eaten the biscuits and gravy they had for breakfast that morning, but none was reserved for him. He was very picky about foods and they offered him an alternate but when he did not like the alternate either he wouldn't eat anything. The alternates included burgers and salads but didn't include foods the resident liked such as macaroni and cheese, tuna fish, fried chicken, chicken fingers and sloppy joe. STNA #527 reported if she requested a food Resident #22 liked, but it was not on the alternate list, she was told that's not scheduled and he would not receive it. STNA #527 felt it would be good for the the kitchen manager, diet technician and dietitian to get together so they could meet Resident #22's needs. STNA #527 said the resident sometimes missed many meals in a row. Interview with Resident #22 on 01/14/20 at 2:10 P.M. verified he had no breakfast or lunch this day. He said he requested his energy drink and had yet to receive it. He verified missing many meals because he slept until after noon and because they served him foods he did not like. He listed the foods STNA #527 identified as his favorites and said he had a strong dislike of turkey but loved sloppy joe. Interview with Registered Dietitian (RD) #543 on 01/14/20 at 3:02 P.M. reported she only consulted with the facility one day a month. She said if a resident refused meals they had a whole kitchen full of foods that could be made to accommodate them. RD #543 said there were a number of ways to handle Resident #22's frequent refusals. They could talk with him, could hold his breakfast until later and could serve him a heavy evening snack. Interview was conducted with the Diet Technician #427, Dietary Manager #426 and the Administrator on 01/14/20 at 03:26 P.M. and they were informed there was no individualized meal plan set up for Resident #22, and no evidence his likes or dislikes were obtained. They reported his likes and dislikes were listed on his meal ticket. Review of Resident #22's meal ticket indicated he liked fortified cereal, cheeseburgers and macaroni and cheese. No food dislikes were listed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365134 If continuation sheet Page 3 of 5 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 365134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Ridge Nursing & Rehabilitation Center 721 Hickory St Akron, OH 44303 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review the facility failed to ensure medication was properly administered via a percutaneous endoscopic gastrostomy (peg) tube. This affected one resident (Resident #139) of four residents observed for medication administration. There was only one resident identified with a gastrostomy tube in the facility. Findings include: Resident #139 was admitted to the facility on [DATE]. His admitting diagnoses included type II diabetes, cerebral infarction, aphasia, epilepsy, hypertension, Alzheimer's disease and adult failure to thrive. Review of a Minimum Data Set, dated [DATE] revealed the resident had moderate cognitive impairment and was totally dependent on staff for eating due to the resident having a peg tube (a tube inserted into the abdomen for the purpose of providing medications and nutrition for those unable to take these by mouth). Review of the physician order dated 08/08/18 revealed the resident was to receive liquid Potassium Chloride (a supplement) 20 milliequivalents (mEq) via peg tube three times a day. Observation on 01/14/20 at 9:00 A.M. during medication administration for Resident #139 revealed Licensed Practical Nurse (LPN) #453 entered Resident #139's room and administered the Potassium Chloride 20 mEq. At the time of the observation the tube feeding bag was empty but still attached to the resident's gastrostomy tube. LPN #453 stated a bolus of tube feeding solution had just finished infusing. There was no tube feeding solution visibly remaining in the bag or tubing. LPN #453 proceeded to pour the potassium chloride liquid into the feeding bag and let it infuse by gravity into the resident's stomach. He then poured 20 cubic centimeters (cc) of water into the feeding bag and let the water infuse into the resident's stomach. When this was done he disconnected the tubing of the feeding bag from the gastrostomy tube. On 01/14/20 at 9:15 A.M. LPN #453 verified he did not check placement or for residual before giving the Potassium Chloride because he had done so before giving the bolus feeding. When asked why he did not disconnect the feeding bag tubing and administer the medication medication directly into the peg tube, LPN #453 said he did not have an order to push the medication in via syringe. LPN #453 also verified he did not flush the peg tube with a full 30 ccs of water prior to and then again after administration of the medication. Review of the facility policy titled Medication Administered Through an Enteral Tube dated 01/22/13 revealed after unclamping the tube, the nurse should check placement by inserting a small amount of air into the tube with a syringe and listen with a stethoscope for placement and/or insert the syringe in the tube and pull back the plunger to aspirate gastric contents. The nurse was then to administer 30 cc of warm water or per the physician's order, then pour the medication into the syringe. The medication was to flow in via gravity from the syringe. At the end of the administration of the medication the nurse was to flush the feeding tube with 30 cc of warm water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365134 If continuation sheet Page 4 of 5 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 365134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Ridge Nursing & Rehabilitation Center 721 Hickory St Akron, OH 44303 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and policy review the facility failed to ensure the kitchen floor, storage areas and equipment was maintained in a clean manner, foods were properly stored in the refrigerator and freezer, and foods were served to the residents in a sanitary manner. This had the potential to affect all 146 residents currently residing in the facility who received food prepared in the kitchen. Findings include: 1. Initial tour of the kitchen on 01/12/20 at 9:00 A.M. revealed papers, multiple food crumbs, and a piece of plastic silverware on the floor in the hallway where the freezer and refrigerator were kept. Behind the ice machine, which was located in the same area there was an accumulation of dust, dirt and a disposable plastic cup. Additionally, food crumbs were observed inside the microwave. 2. Observation of the freezer revealed three sheet pans containing frozen breadsticks, and a bag containing cooked hamburger patties that were not labeled with a date or time. Additional items not labeled with a date or time found in the refrigerator included three steam table pans filled with frozen mixed vegetables on a cart, a large plastic container filled with chocolate pudding on a second cart, and a large metal bowl with hamburger buns on the top shelf. Interview with Dietary Manager #426 and Dietician Tech #427 on 01/12/20 at 10:00 A.M. verified the above findings. 3. Observation during the dinner meal on 01/14/19 in the main dining room at 5:35 P.M. revealed Dietary Aide (DA) #419 plating foods from the steam table. DA #419 was observed using her bare hands to put french fries onto a resident's plate. DA #419 was also observed obtaining plates from the lower shelf under the steam table, and handling meal tickets brought into the kitchen from resident tables the dining room. DA #419 did not wash her hands after obtaining plates or handling meal tickets and continued to plate the french fries with her bare hands. Interview with Dietary Manager #426 on 01/20/20 at 5:45 P.M. DA #419 was plating foods with her bare hands and did not wash her hands appropriately. Review of the facility policy titled Food Storage-Labeling and Dating dated 07/18 revealed items must be dated after opening with an open date and a Use by Date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365134 If continuation sheet Page 5 of 5