Deficiencies (last 5 years)
Deficiencies (over 5 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
147 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 147
Deficiencies: 5
Date: Jan 28, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to ensure safe transfers, assistance with activities of daily living, fall prevention interventions, accurate documentation, and infection prevention and control practices at Hickory Ridge Nursing & Rehabilitation Center.
Complaint Details
This inspection was conducted under Complaint Numbers OH00161220, OH00161120, and OH00161669.
Findings
The facility failed to ensure Resident #65's care plan clearly reflected safe transfer interventions, failed to consistently assist Resident #17 with shaving, failed to maintain fall prevention interventions for Residents #65 and #137, failed to accurately document fall prevention interventions for Resident #137, and failed to ensure proper hand hygiene and enhanced barrier precautions for Residents #65, #8, and #58. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (5)
Failed to ensure Resident #65's care plan clearly reflected interventions to be used for safe transfer.
Failed to provide consistent assistance with shaving for Resident #17.
Failed to ensure safe transfer of Resident #65 resulting in a fall and failed to maintain Resident #137's care planned interventions to prevent falls.
Failed to ensure staff accurately documented the presence of interventions to prevent a fall for Resident #137.
Failed to ensure staff performed appropriate hand hygiene and implemented enhanced barrier precautions affecting Residents #65, #8, and #58.
Report Facts
Facility census: 147
Residents reviewed for falls: 3
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
Residents affected by deficiencies: 1
Residents affected by deficiencies: 3
Residents on 100 unit: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #150 | Certified Nursing Assistant | Named in infection control and fall prevention findings |
| CNA #152 | Certified Nursing Assistant | Named in fall incident involving Resident #65 |
| CNA #153 | Certified Nursing Assistant | Named in shaving assistance deficiency for Resident #17 |
| CNA #154 | Certified Nursing Assistant | Named in shaving assistance deficiency for Resident #17 |
| Administrator | Interviewed regarding care plan revisions and findings | |
| Regional Clinical Director | Interviewed regarding care plan revisions and findings | |
| Assistant Director of Nursing | Interviewed regarding fall prevention and infection control findings | |
| Director of Nursing | Conducted training for CNA #152 on mechanical lift use |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 1
Date: Jun 17, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide timely oral care to residents.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00154437.
Findings
The facility failed to provide oral care in a timely manner to Resident #1, as documented by missing oral care records on multiple dates and observations of poor oral hygiene. This deficiency was confirmed through medical record review, staff interviews, and direct observation.
Deficiencies (1)
Failure to provide oral care in a timely manner to Resident #1, with multiple days lacking documentation of oral care completion.
Report Facts
Census: 139
Dates with no oral care documentation: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #204 | State Tested Nurse Assistant | Named in relation to failure to complete oral care for Resident #1 |
| ADON #208 | Assistant Director of Nursing | Verified oral care was not documented as completed for Resident #1 |
| ADON #210 | Assistant Director of Nursing | Verified oral care was not documented as completed for Resident #1 |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Date: Jul 25, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of sexual abuse involving two residents.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00144686.
Findings
The facility failed to timely report an allegation of sexual abuse between Resident #94 and Resident #64. The investigation revealed conflicting statements from residents and staff, with evidence of inappropriate sexual behavior and a delay in reporting to the Ohio Department of Health. The facility policy requires immediate reporting of such allegations, which was not followed.
Deficiencies (1)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents affected: 2
Facility census: 145
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #210 | Licensed Practical Nurse | Notified about sexual inappropriateness between residents |
| State Tested Nursing Assistant #200 | State Tested Nursing Assistant | Witnessed inappropriate behavior and reported it |
| Interim Administrator | Interim Administrator | Verified delay in reporting the incident to the Ohio Department of Health |
| Director of Nursing | Director of Nursing | Started investigation and filed the Self-Reported Incident |
Inspection Report
Census: 128
Deficiencies: 1
Date: Jan 12, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and palatability standards, specifically ensuring that food and drink are served at safe and appetizing temperatures.
Findings
The facility failed to ensure foods were palatable and served at appropriate temperatures, with multiple residents reporting cold and unappetizing food. A test tray review confirmed that food items were served cold and lacked flavor, violating facility policy.
Deficiencies (1)
Failed to ensure food and drink were palatable and served at appropriate temperatures.
Report Facts
Residents affected: 127
Facility census: 128
Food temperatures: 111
Food temperatures: 114
Food temperatures: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager (CDM) #700 | Conducted test tray review and temperature measurements |
Inspection Report
Routine
Census: 147
Deficiencies: 4
Date: Jan 15, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, nutrition, medication administration, and food safety at Hickory Ridge Nursing & Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including failure to provide a safe, sanitary, and comfortable environment due to persistent offensive odors and damaged wallpaper; failure to develop and implement an individualized meal plan for a resident leading to inadequate nutrition; improper medication administration via a feeding tube; and unsanitary food storage and handling practices in the kitchen.
Deficiencies (4)
Facility failed to provide a safe, functional, sanitary and comfortable environment for residents on the 600 unit, including persistent offensive odor and torn wallpaper.
Failed to develop and implement an individualized meal plan to meet Resident #22's nutritional needs, resulting in weight loss and missed meals.
Failed to ensure medication was properly administered via a percutaneous endoscopic gastrostomy (peg) tube for Resident #139, including not checking tube placement before medication administration and not flushing the tube properly.
Failed to maintain kitchen floor, storage areas, and equipment in a clean manner; failed to properly label and date food items; and failed to ensure food was served in a sanitary manner.
Report Facts
Residents affected: 27
Facility census: 147
Weight loss percentage: 5.3
Supplement dosage: 120
Potassium Chloride dosage: 20
Water flush volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #455 | Verified persistent odor on 600 unit | |
| Licensed Practical Nurse (LPN) #454 | Staff interview regarding resident care and odor persistence | |
| Licensed Practical Nurse (LPN) #451 | Staff interview regarding resident care and odor persistence | |
| State Tested Nurse Aide (STNA) #492 | Staff interview regarding resident care and odor persistence | |
| State Tested Nurse Aide (STNA) #529 | Staff interview regarding resident care and odor persistence | |
| Administrator | Confirmed awareness of odor and behavioral unit status | |
| Maintenance Director #475 | Environmental tour verifying torn wallpaper | |
| Housekeeping Supervisor #442 | Environmental tour verifying torn wallpaper | |
| Licensed Practical Nurse (LPN) #465 | Reported Resident #22 never ate breakfast and intake issues | |
| Dietary Manager #427 | Reported Resident #22's eating habits and supplement changes | |
| State Tested Nurse Aide (STNA) #527 | Reported Resident #22's meal refusals and food preferences | |
| Registered Dietitian (RD) #543 | Reported consultation frequency and meal refusal accommodations | |
| Diet Technician #427 | Interviewed about Resident #22's meal plan | |
| Dietary Manager #426 | Interviewed about Resident #22's meal plan and kitchen sanitation | |
| Licensed Practical Nurse (LPN) #453 | Observed administering medication improperly via peg tube to Resident #139 | |
| Dietary Aide (DA) #419 | Observed plating food with bare hands and poor hand hygiene |
Inspection Report
Routine
Census: 148
Deficiencies: 8
Date: Nov 29, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident care, abuse prevention, Minimum Data Set (MDS) assessments, staffing, food service, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate abuse allegations, failure to submit timely and accurate MDS assessments for all residents, insufficient nursing staff to assist residents with meals, failure to follow menu serving sizes, unsanitary kitchen and nursing unit conditions, and failure to maintain a clean and safe environment in resident areas.
Deficiencies (8)
Failed to implement abuse policy to ensure one Self-Reported Incident (SRI) investigation was complete and thoroughly investigated affecting two residents.
Failed to submit Minimum Data Set (MDS) assessments within 14 days of completion for all 151 residents during 07/12/18 through 10/22/18.
Failed to ensure Minimum Data Set (MDS) assessments were accurate for four residents reviewed.
Failed to ensure sufficient nursing staff to assist residents with meals, affecting four residents needing eating assistance.
Failed to ensure the menu was followed for serving size of all foods, affecting 146 residents.
Failed to ensure sanitary conditions in the kitchen and nursing unit, affecting 146 residents.
Failed to administer the facility effectively to ensure continuity of care during change of ownership related to MDS assessment transmissions.
Failed to maintain a clean and sanitary environment in resident areas, affecting five residents and potentially all residents on the 500 unit.
Report Facts
Residents affected: 2
Residents affected: 151
Residents affected: 4
Residents affected: 4
Residents affected: 146
Residents affected: 146
Residents affected: 5
Facility census: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional MDS Registered Nurse #501 | Regional MDS RN | Interviewed regarding MDS assessment submission and change of ownership issues |
| Chief Operating Officer #502 | COO | Interviewed regarding failure to submit MDS assessments and penalties |
| Registered Nurse #805 | RN | Interviewed regarding inaccurate MDS assessments for residents |
| Social Service Designee #500 | SSD | Interviewed regarding MDS assessment completion and resident refusals |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding insufficient nursing staff to assist with feeding residents |
| Registered Nurse #3 | RN | Observed assisting resident with meal |
| State-Tested Nurse Aide #2 | STNA | Observed assisting resident with meal |
| Dietary Manager #5 | DM | Interviewed regarding menu serving sizes and kitchen sanitation |
| Registered Dietitian #4 | RD | Interviewed regarding kitchen sanitation |
| [NAME] #6 | Observed and interviewed regarding food temperatures and serving sizes | |
| [NAME] #7 | Observed preparing food without beard guard | |
| Registered Nurse #801 | RN | Observed and verified unsanitary conditions in resident areas |
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