Inspection·June 27, 2024

F 0812 of the steam table. Level of Harm - Minimal harm or potential for actual harm - The metal chest style food warmer had a thick coating of dried food on the inside surfaces of the food warmer. Residents Affected - Many - The walls in the kitchen had a greasy film with dried food/liquid present on the walls surrounding the food preparation and dishwashing area. - The dishwashing area had water leaking from a pipe under the dishwashing station with a plastic tub placed under the pipe to catch the leaking water. The water in the plastic tub was dark brown/black and had food particles floating in the water. There was an unpleasant odor emanating from the water in the plastic tub. Interview on 06/27/24 at 9:00 A.M with [NAME] #46 confirmed the Surveyor's concerns identified during the kitchen tour. [NAME] #46 further confirmed the facility did not have the proper cleaning products available to properly clean the stove, oven and other cooking equipment. [NAME] #46 stated the floors were not mopped and swept on a daily basis. [NAME] #46 stated the kitchen floors had not been cleaned appropriately for approximately five to six months. [NAME] #46 stated she had notified the KM of the need for proper cleaning supplies and a consistent routine for cleaning the kitchen several times during the past few months. [NAME] #46 stated the kitchen staff during the evening shift from 4:00 P.M. to 8:00 P.M. did not have proper supervision to ensure the daily cleaning duties were performed. Observation on 06/27/24 at 9:06 A.M. of the area outside of the kitchen exit door and entering the dining room area revealed the meal service area cupboards and counters had dried food/liquid spills on the floor, counters and cupboard doors. There were papers and other clutter placed on the counters in the meal service area. Interview on 06/27/24 at 9:08 A.M. with Dietary Aide (DA) #47 confirmed the meal service area was dirty with dried food spills and was cluttered with nonessential items. Interview 06/27/24 at 10:00 A.M. with [NAME] #46 confirmed she was unable to find any completed cleaning duties checklists. [NAME] #46 confirmed staff were supposed to completed the checklist daily and initial on the form and then turn the form into the KM. Review of the facility document titled Cleaning Duties Checklist for the A.M. undated revealed the kitchen staff were supposed to initial and check out with the KM when the duties were completed each day. The duties included to change the sanitization buckets every two hours, throw away old and used products in the food cooler, organize the food cooler and freezer, ensure all food products were labeled and dated appropriately, sanitize and clean debris on the three-sink compartment area, wash pots/pans and clean all sinks, remove the trash, complete the food preparation for the following day, clean/sanitize the steam table and organize the area, sweep and mop the floors in the kitchen from the ice machine to the dry storage area, clean the steamer/stovetop/oven and shut down all appliances, check with the dietary aides to assist them if needed and check out with the dietary manager after completion of the checklist. The checklist had an area for the staff member to place their initials with the date at the bottom of the form. Review of the facility document titled Cleaning Duties Checklist P.M. undated revealed kitchen staff were supposed to change the sanitization buckets every two hours, wipe down/sanitize all work (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 2 of 3 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd 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 areas, fill out temperature logs, organized the spice shelf and remove clutter from the long shelf against the wall, sweep and mop the service line/front table are/preparation areas, wash pots/pans and clean all sinks, complete preparation needed for the next shift, organize the dry storage area and ensure all food items were off the floor, take snacks down to all the floors, clean the microwave and toaster, remove trash from the kitchen, clean the steam table/service area, assist dietary aides as needed and to check out with the kitchen manager to ensure all duties were completed. The checklist had an area for the staff member to place their initials with the date at the bottom of the form. This deficiency represents noncompliance investigated under Complaint Number OH00155055. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 3 of 3