F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interviews, the facility failed to timely report an allegation of sexual abuse involving
Resident #94 and Resident #44 to the state agency. This affected two residents (Resident #64 and #94) of
three reviewed for abuse. The facility census was 145.
Findings included:
Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Diagnoses
included diabetes, inflammatory spondylopathy, chronic obstructive pulmonary disease, nutritional
marasmus, heart failure, neurogenic bowel, schizophrenia, anxiety disorder, hypertension, neuromuscular
dysfunction of the bladder, COVID-19, and paraplegia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had
moderately impaired cognition with no behaviors. He required extensive assistance from one staff member
for bed mobility, transfers, dressing toilet use and personal hygiene. Further review revealed he was
incontinent of bowel and bladder.
Review of the medical record revealed Resident #64 was admitted to the facility 02/16/18. Diagnoses
included dementia, paranoid schizophrenia, epilepsy, anxiety disorder, alcohol abuse, nicotine dependence,
COVID-19, left leg amputation, major depressive disorder, severe protein-calorie malnutrition, adult failure
to thrive, vitamin D deficiency, and constipation.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #64 had intact cognition and he
had no behaviors.
Review of the incident note dated 07/16/23 at 5:43 A.M. revealed Resident #64 was noted to be sexually
inappropriate with his roommate (Resident #94). They were separated and Resident #94 was moved to a
new room on the 100 Hall. Resident #94 was interviewed by the nursing supervisor and stated he was fine,
not hurt and was okay with moving to a new room.
Review of the social service note dated 07/16/23 at 9:42 A.M. revealed the Licensed Social Worker (LSW)
interviewed Resident #64 and he denied any sexual behavior between him and his previous roommate. His
last documented Brief Interview for Mental Status score was 15.
Review of a signed witness statement dated 07/16/23 written by State Tested Nursing Assistant (STNA)
#200 at 4:45 A.M. indicating she noticed the door of room [ROOM NUMBER] was shut so she went into the
room to check on the residents. The resident in bed two (Resident #94) was in bed naked and 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 2
Event ID:
365134
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
07/25/2023
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
resident in bed one (Resident #64) was digging in the rectum of Resident #94. Resident #64 been in the
bed with Resident #94. She indicated there was bowel movement (BM) all over the bed. The linens were on
the floor with BM on them.
Review of the signed witness statement dated 07/16/23 by Licensed Practical Nurse (LPN) # 210 revealed
at approximately 4:50 A.M. the charge nurse and STNA notified LPN #210 that Resident #94 and Resident
#64 were being sexually inappropriate. Both residents denied anything sexual occurred between them.
On 07/20/23 at 3:15 P.M. an interview with Resident #94 revealed he was confused, he stated he was
practicing his praying, and was going on about his brother not coming to see him. He stated he did not think
he was sexual assaulted.
On 07/20/23 at 4:15 P.M. an interview with the Interim Administrator verified they had not reported the
incident to the Ohio Department of Health on 07/16/23 because they did not feel it was sexual abuse. She
stated they believe Resident #94 had asked Resident #64 to help him. She stated they had been
roommates for years with no problems.
On 07/20/23 at 4:17 P.M. an interview with the Director of Nursing (DON) revealed the niece of Resident
#94 came into the facility on [DATE] around 11:00 P.M. with the Akron police alleging there was sexual
abuse against her uncle by Resident #64. She stated the niece demanded Resident #94 go to the hospital
to be checked out. She stated Resident #94 did not want to go to the hospital but finally went after the niece
persisted. She stated the hospital would not give them any paperwork because the resident was his own
responsible party. She stated at that point she started the investigation and filed the Self-Reported Incident.
Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property,
dated 11/21/16, revealed it was the facility policy to investigate all alleged violations of abuse, neglect,
exploitation, mistreatment of the resident or misappropriation of resident property including injuries of
unknown source. Additionally, the facility should immediately report all such allegation to the Administrator
and the Ohio Department of Health .
This deficiency represents non-compliance investigated under Complaint Number OH00144686.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365134
If continuation sheet
Page 2 of 2
