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, staff interview and policy review, the facility failed to ensure food was prepared and
served in a sanitary manner. This had the potential to affect 76 of 77 residents residing in the facility. The
facility identified one resident (Resident #19), to receive an alternate form of nutrition not provided by the
kitchen.
Findings include
On 04/21/23 at 11:30 A.M. observation of the tray line revealed Dietary [NAME] #284 used her gloved
hands to brush crumbs off of the counter, obtained scoops from a drawer, touched a food cart and obtained
a pair of tongs from a drawer. The Dietary [NAME] returned to the tray line, without removing her gloves and
washing her hands, opened a package of sandwich buns and placed a piece of fish on the bun using her
gloved hands instead of tongs. The Dietary [NAME] was observed to continue to place pieces of fish onto
sandwich buns using either her hands or tongs.
On 04/21/23 at 11:37 A.M. interview with Dietary Manager #212 verified the observations and stated the
cook should have changed her gloves and washed her hands before returning to the tray line to plate the
food.
Review of the un-dated facility policy and procedure Preventing Food Borne Illness-Food Handling revealed
food will be stored, prepared, handled and served so that the risk of food borne illness is minimized.
This deficiency represents non-compliance investigated under Complaint Number OH00141291.
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:
365485
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
365485
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/21/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Flint Ridge Nrsg & Rehab Ctr
1450 West Main Street
Newark, OH 43055
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation and staff interview, the facility failed to maintain a sanitary and comfortable
environment . This had the potential to affect 22 residents (Resident #5, #7, #11, #17, #19, #20, #21, #23,
#26, #28, #29, #33, #35, #37, #40, #52, #58, #61, #67, #69, #74 and #77) of 77 residents residing in the
facility.
Findings include:
On 04/21/23 between 11:54 A.M. to 12:10 P.M. observations with the Administrator revealed the following:
In Resident #17's room, the drywall was cracked with the baseboard coming loose from the wall.
In Resident #28 and #33's room, the drywall was cracked with the baseboard coming loose from the wall,
the paint was chipped by the bed, a hole the size of a 50-cent piece was noted in the bathroom door, next
to a dresser the corner drywall was worn and exposed the metal corner molding.
In Resident #61's room, dark stains were noted on the flooring and the drywall was scuffed.
In Resident #26's room, the entrance to their bathroom was missing a 12 inch by four-inch area of tile and
the flooring in the bathroom was worn and had rust-colored stains.
In Resident #19 and #74's room, the floor had three different colors of tiles that had been used for
replacement tiles and a large amount of dry enteral feeding on a feeding pump pole.
The wall railing between Resident #26 and #40's rooms was scuffed and needed painted. This included
Residents #5, #7, #11, #20, #21, #23, #26, #29, #35, #37, #40, #52, #58, #61, #67, #69 and #77 rooms.
These findings were verified with the Administrator at the time of the observations.
This deficiency represents non-compliance investigated under Complaint Number OH00141291.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365485
If continuation sheet
Page 2 of 2
