Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at O'brien Memorial Health Care C during CMS and state inspections, most recent first.
A resident with dementia, chronic pain, and vertebral compression fractures received repeated PRN Tramadol doses for reported pain levels ranging from zero to nine, along with scheduled acetaminophen. Although the care plan called for non-drug pain measures such as heat, rest, or distraction, the record contained no documented evidence that nonpharmacological interventions were attempted before opioid administration. An LPN said such interventions were offered and documented in progress notes, but the DON confirmed the documentation was not present and that Tramadol had been consistently given for mild to moderate pain.
A resident with Alzheimer's, COPD, and hypertension experienced a significant decline, including severe weight loss and changes in mentation and activity, without timely documentation, physician notification, or required wound care and weight monitoring. The resident was ultimately hospitalized with sepsis, aspiration pneumonia, fecal impaction, and UTI after family insisted on transfer, and facility leadership confirmed failures in care and communication.
The facility failed to provide adequate RN coverage for at least eight consecutive hours a day, seven days a week, affecting all 68 residents. The Facility Annual Assessment and PBJ Staffing Data Report showed multiple days without RN coverage, resulting in a one-star staffing rating. Interviews revealed a misunderstanding of the coverage requirements, with the Administrator believing only two hours of RN coverage were needed.
The facility failed to maintain a clean and sanitary kitchen, affecting 75 residents who consumed food prepared there. Observations revealed unclean handwashing stations, dried food debris, and mold-like spots in the walk-in cooler. The facility's policies for cleaning were not followed, and previous inspections noted similar violations. Two residents were not affected as they received no nourishment by mouth.
The facility failed to implement proper infection control precautions for three residents, including a resident with a tracheostomy, a resident with an unstageable wound, and a resident with MRSA. Nurses did not follow enhanced barrier precautions (EBP) or transmission-based precautions (TBP) as required, and there was a lack of appropriate signage and personal protective equipment (PPE) available. These deficiencies were contrary to the facility's policies, potentially affecting all residents.
The facility failed to store food properly, with numerous items found open and undated in the kitchen's dry storage, cooler, refrigerator, and freezer. Expired hoagie buns and improperly stored items on the floor were also noted. A staff member confirmed the need for proper labeling and storage, aligning with the facility's policy. This deficiency had the potential to affect all residents receiving food from the kitchen.
The facility administered expired tuberculin tests to 12 residents, as revealed by an observation in the medication storage room. A bottle of Tuberculin, Purified Protein Derivative, was found expired, and the RN confirmed and discarded it. The facility's policy required following manufacturer expiration dates, which was not adhered to.
A facility failed to follow physician's orders for constant one-on-one supervision of a resident with behavioral issues, resulting in two incidents of resident-to-resident abuse. Despite orders and facility policy, the resident was left unsupervised, highlighting a deficiency in protecting residents from abuse.
A facility failed to maintain a functioning alarm for a resident with dementia, as ordered by the physician. The resident's bathroom door alarm, intended to prevent confusion and entry into an adjacent room, was not consistently checked or documented as functional from March to June. Observations in June revealed the alarm was not working, and an LPN admitted staff often forgot to reactivate it, contrary to facility policy.
A resident with leukemia did not receive prescribed oral chemotherapy medications due to unavailability and insurance issues. The facility failed to notify the oncologist about the medication issues, and the facility's policy lacked guidance on handling unavailable medications, resulting in significant medication errors.
The facility did not complete reference checks for seven employees, including nurse aides, LPNs, a housekeeper, and a dietary supervisor, potentially affecting all 81 residents. The Administrator confirmed the lack of documentation during an interview.
The facility did not complete required evaluations for STNAs within 90 days of hire and annually, affecting six STNAs and potentially impacting all 81 residents. Missing evaluations were confirmed by the Administrator.
The facility did not verify an LPN's active and unrestricted nursing license before hiring. The absence of documented evidence of license verification was confirmed by the Administrator. Although the LPN's license was later confirmed to be active and unrestricted, this verification happened post-hire.
The facility failed to protect three residents from sexual abuse by another resident with a history of inappropriate behavior. Despite measures such as 15-minute checks and one-on-one supervision, the resident continued to exhibit sexually abusive behavior, indicating a failure to ensure the safety and well-being of the residents.
The facility failed to ensure residents were free from significant medication errors, affecting two residents. One resident received fourteen incorrect medications, leading to emesis and a hospital visit, while another resident did not receive several medications as ordered upon admission due to a failure to fax the orders to the pharmacy. The facility's medication administration policy was not followed in both cases.
Lack of documented nonpharmacological pain interventions before opioid use
Penalty
Summary
The facility failed to have documented evidence that nonpharmacological interventions were attempted before administering opioid pain medication to one resident. Resident #12 was admitted with diagnoses including alcohol dependence, dementia, kidney failure, obesity, high cholesterol, bipolar disorder, chronic pain, vertebral compression fractures, and anxiety. The quarterly MDS indicated she was severely cognitively impaired and required varying levels of assistance with activities of daily living. Resident #12 had physician orders for Tramadol 50 mg every eight hours as needed for moderate to severe pain, beginning 12/05/25, and scheduled Acetaminophen Extra Strength 500 mg two tablets three times daily. Her care plan identified chronic pain related to spinal fusion and compression fractures and included interventions to attempt non-drug pain treatments such as heat, rest, or distraction, and to evaluate and document the effectiveness and probable cause of each pain episode. Review of the MAR from January through early March 2026 showed repeated administration of Tramadol for reported pain levels ranging from zero to nine, along with scheduled acetaminophen. Review of the progress notes for the same period found no documented evidence that nonpharmacological interventions were attempted prior to opioid administration. During interview, the LPN stated that nonpharmacological interventions were offered and documented in progress notes, while the DON confirmed there was no documented evidence that such interventions were attempted consistently for this resident and that Tramadol had been consistently given for mild to moderate pain.
Failure to Provide Care per Physician Orders and Timely Address Change in Condition
Penalty
Summary
The facility failed to provide care in accordance with physician orders and did not timely identify or address a significant change in condition for a resident with Alzheimer's disease, COPD, and hypertension. The resident had care plans in place for nutritional monitoring and incontinence, as well as physician orders for weekly weights and daily wound care. However, documentation revealed that wound care was not provided on multiple ordered dates, and weekly weights were missed, including during a period of significant weight loss. The resident experienced a 7.5% weight loss in less than 30 days, but there was no evidence that the physician was notified of this severe decline, nor were further weights documented after the initial identification of weight loss. From 03/16/25 to 03/22/25, there was no documentation or physician notification regarding changes in the resident's baseline mentation, eating patterns, or activity level, despite the resident exhibiting a decline in these areas. Nursing notes only documented the resident's condition after family members expressed concern and insisted on hospital transfer. The facility's own policy required staff to document and notify the physician and family of significant changes in condition, but this was not followed. Upon transfer to the hospital, the resident was diagnosed with sepsis related to aspiration pneumonia, fecal impaction, acute metabolic encephalopathy, and urinary tract infection. Hospital records indicated the presence of a fecal impaction, a severe urinary tract infection, and aspiration pneumonia, all of which were not addressed or communicated by facility staff prior to transfer. Interviews with facility leadership confirmed the missed wound care, lack of documentation, and failure to notify the physician or family of the resident's decline.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to ensure adequate Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency had the potential to affect all 68 residents residing in the facility. The Facility Annual Assessment did not specify the required RN coverage, and the Payroll Based Journal (PBJ) Staffing Data Report revealed multiple days within the quarter where there was no RN coverage, resulting in a one-star staffing rating. The facility's tracking calendars for several months confirmed numerous days without the required RN coverage. Interviews with the Regional Administrator and the facility Administrator revealed a misunderstanding of the RN coverage requirements. Both verified the absence of an RN on the specified days and confirmed the accuracy of the PBJ Report. The Administrator mistakenly believed that only two hours of RN coverage per day were necessary, rather than the required eight hours. This deficiency was investigated under Complaint Number OH00161619.
Facility Fails to Maintain Kitchen Cleanliness
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect 75 of the 77 residents who consumed food prepared there. During an observation on August 7, 2024, multiple cleanliness issues were noted, including unclean handwashing stations with water stains, soap scum, and grime around the faucets and handles. One handwashing station lacked paper towels. Additionally, dried food debris was found on a shelf beneath a workstation, and employee personal items were improperly stored on top of the workstation. The walk-in cooler was observed to have dark black spots, resembling mold, on the shelving units, walls, and ceiling, and the fan was covered in black dust. The floor and seams of the cooler had dried food and other unidentified debris. The Regional Administrator confirmed the presence of what appeared to be mold in the walk-in cooler, leading to the disposal of any unsealed food. A review of the State of Ohio Food Inspection Report from July 30, 2024, indicated repeat violations for cleanliness of equipment and food contact surfaces, as well as the absence of paper towels at the handwashing sink. The facility's policies required deep cleaning of the kitchen floor every four to six weeks and weekly cleaning of the walk-in cooler, which were not adhered to. Two residents were noted to receive no nourishment by mouth, thus were not affected by the kitchen's condition.
Failure to Implement Proper Infection Control Precautions
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions (TBP) and enhanced barrier precautions (EBP) for three residents, potentially affecting all 81 residents. Resident #179, who had a tracheostomy, did not have EBP signage or personal protective equipment (PPE) available near the room entrance. During tracheostomy care, nurses did not wear gowns as required by the facility's EBP policy. Resident #56, with an unstageable wound, was not placed under EBP, as the wound was not considered chronic by the staff. This decision was contrary to the facility's policy, which requires EBP for high-contact resident care activities. Resident #15, diagnosed with a non-pressure chronic ulcer and MRSA, was not properly isolated. Although the care plan indicated contact isolation, there was no signage on the resident's door to alert staff and visitors. During an observation of intravenous medication administration, the nurse did not follow EBP for device care, mistakenly believing it was only for wound care. The facility's policy required gown and gloves for contact isolation, which were not used. The lack of proper precautions and signage for Resident #15's MRSA infection highlights a failure to adhere to the facility's infection control policies.
Food Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that food was stored in a manner that prevents contamination and foodborne illness, as observed during a survey. In the kitchen's dry storage area, several items were found open and undated, including a bag of potatoes, cornflakes, Cheerios, pancake batter, pasta, and a jar of syrup. Additionally, three bags of hoagie buns were found to be expired. In the cooler, various open and undated items were discovered, such as packs of strawberries, bags of lettuce, a container of salad mix, a tomato, half an onion, a bag of cucumbers, and prepared cups of juice. The refrigerator contained open and undated items like hard-boiled eggs, chicken breasts, lunch meat, shredded cheese, chicken noodle soup, cooked bratwurst, and applesauce. A bucket of pickles was found open and undated on the floor, and a gallon of milk was missing its cap. The freezer also contained open and undated items, including mixed vegetables, sausage links, green beans, chicken tenders, and a frozen pizza, with some boxes stored directly on the floor. An interview with a staff member confirmed that food should be labeled with both an open and use-by date, and no boxes should be stored on the floor. The facility's policy on covering, labeling, and dating food, which was reviewed during the survey, stated that all food stored should be covered, labeled, and dated, with fresh fruits containing a received-on date, and food should be discarded by the manufacturer's use-by or sell-by date. This deficiency was investigated under Complaint Number OH00154456 and had the potential to affect all residents who received food from the kitchen, although two residents were identified as receiving no food by mouth.
Expired Medication Administration
Penalty
Summary
The facility failed to ensure that medications were disposed of when they had expired, specifically affecting 12 residents who received expired tuberculin tests. An observation in the medication storage room revealed a bottle of Tuberculin, Purified Protein Derivative, Diluted Aplisol, which was expired. The Registered Nurse present confirmed the expiration and discarded the medication. A review of the facility's records showed that the expired medication was administered to 12 residents after its expiration date. The facility's policy on medication administration required adherence to manufacturer instructions for expiration dates, which was not followed in this instance.
Failure to Follow Supervision Orders Leads to Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure physician's orders were followed to prevent potential resident-to-resident abuse, affecting three residents. Resident #37, diagnosed with schizoaffective disorder bipolar type, mild cognitive impairment, and anxiety, was involved in two incidents where she slapped other residents. Following these incidents, she was placed on 15-minute checks and a door alarm was installed. Despite a physician's order for constant one-on-one supervision, observations revealed that Resident #37 was left unsupervised in her room, with no staff present in the hallway or her room. On one occasion, a State Tested Nurse Aide (STNA) was the only staff member on the unit, caring for six residents, and left Resident #37 unsupervised while another STNA was on a break. The Director of Nursing confirmed that Resident #37 required one-on-one supervision due to escalated behaviors. The facility's policy on Resident Abuse Prevention Practices was not adhered to, as staff failed to maintain the required supervision, leading to a deficiency in protecting residents from abuse.
Failure to Maintain Functioning Alarm for Resident with Dementia
Penalty
Summary
The facility failed to maintain a functioning alarm for a resident diagnosed with dementia, as ordered by the physician. The resident had a physician's order for a door alarm on the bathroom door that exited into an adjacent room, intended to alert staff if the resident attempted to enter the wrong room. The facility's records, including the medication administration record (MAR) and treatment administration record (TAR), showed that staff did not document the alarm's functionality on several occasions from March to June 2024. This lack of documentation indicates that the alarm was not consistently checked as required. During observations and interviews conducted in June 2024, it was found that the alarm on the bathroom door was not functioning when tested. The resident confirmed the importance of the alarm in preventing confusion and entering the wrong room. An LPN acknowledged that the alarm was often turned off by staff and not turned back on, which was against the facility's policy. The policy required staff to ensure alarms were functioning properly and not to leave residents unattended when alarms were removed or turned off. This deficiency was investigated under a specific complaint number.
Failure to Administer Prescribed Chemotherapy Medications
Penalty
Summary
The facility failed to ensure that a resident with leukemia was free from significant medication errors, as evidenced by the unavailability of prescribed oral chemotherapy medications. The resident was admitted with a diagnosis of leukemia and was prescribed Bosutinib and Nilotinib HCl as part of her treatment. However, the Medication Administration Record revealed that Bosutinib was not administered for several days in January due to the medication not being available. Similarly, Nilotinib was not administered on multiple occasions from January through April due to the medication being on order, not available, or awaiting delivery from the pharmacy. Interviews with facility staff and the resident's physician revealed that the pharmacy did not send the medications due to insurance issues, and the facility failed to notify the oncologist about the unavailability of the medications. The facility's policy on medication administration did not provide guidance on what to do if medications were unavailable, contributing to the oversight. The resident's oncologist was not informed of the medication issues after February, and the facility did not ensure the resident's treatment was uninterrupted, leading to a significant medication error.
Failure to Conduct Employee Reference Checks
Penalty
Summary
The facility failed to ensure that all employees had reference checks completed prior to their hire, affecting seven out of sixteen employees reviewed for abuse. This deficiency had the potential to impact all 81 residents residing in the facility. The employee files reviewed included those of a nurse aide, licensed practical nurses, a housekeeper, and a dietary supervisor, all of whom lacked documented evidence of reference checks upon their respective hire dates. During an interview, the Administrator confirmed the absence of documented reference checks for these employees. This deficiency was investigated under Complaint Number OH00154456, highlighting a significant lapse in the facility's hiring process and compliance with regulations designed to prevent abuse, neglect, and theft.
Failure to Complete STNA Evaluations
Penalty
Summary
The facility failed to ensure that State tested Nurse Aide (STNA) evaluations were completed within the required timeframes, specifically within 90 days of hire and annually thereafter. This deficiency was identified through a review of employee personnel files and interviews, affecting six STNAs out of six reviewed for performance. The absence of documented evaluations had the potential to impact all 81 residents residing in the facility. Specific findings included missing annual evaluations for STNAs hired on various dates in 2021 and 2023, and a missing 90-day evaluation for an STNA hired in October 2023. The Administrator confirmed the lack of evidence for these evaluations during an interview conducted in June 2024.
Failure to Verify LPN License Before Hire
Penalty
Summary
The facility failed to ensure that an LPN had an active and unrestricted nursing license prior to being hired. This deficiency was identified during a review of personnel files, where it was found that there was no documented evidence of license verification for the LPN before their hire date. The issue was confirmed during an interview with the Administrator, who acknowledged the absence of licensure verification documentation in the LPN's file. A subsequent review of a document titled 'License Look Up' confirmed that the LPN did have an active and unrestricted nursing license, but this verification occurred after the hire date.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that three residents were free from sexual abuse. Resident #27, who had a history of inappropriate behavior, was involved in two incidents of sexual abuse towards Resident #65 and Resident #87. Resident #27 was observed by a State Tested Nursing Assistant (STNA) touching Resident #65's breasts on top of her clothes. Both residents were immediately separated, and Resident #27 was moved to a different unit and placed on 15-minute checks. Despite these measures, Resident #27 later kissed and touched the breast of Resident #87, who reported the incident to a Registered Nurse (RN). Resident #27 was then provided with one-on-one staff supervision and sent to the hospital for evaluation. Upon return, Resident #27 was placed on 15-minute checks and later on one-on-one supervision due to continued inappropriate behavior. Resident #65 had severely impaired cognition and a history of physical and verbal aggression, while Resident #87 had intact cognition with no prior behaviors noted. The facility's policy on abuse prevention was reviewed, which defined sexual abuse as non-consensual sexual contact of any type with a resident. The facility's actions included immediate separation of the residents, assessments, notifications to physicians and families, and psychiatric evaluations for Resident #27. However, the facility's measures were insufficient to prevent further incidents of sexual abuse by Resident #27. Interviews with facility staff, including the Regional Administrator, Psychiatric Physician, and Psychiatric Nurse Practitioner, revealed that the sexual behaviors exhibited by Resident #27 were new and unexpected. Despite the facility's efforts to monitor and manage Resident #27's behavior, the incidents of sexual abuse occurred, indicating a failure to protect residents from harm. The facility's policy on abuse prevention was not effectively implemented, leading to the deficiency in ensuring the safety and well-being of the residents involved.
Significant Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting two residents. Resident #47 was administered fourteen incorrect medications by an LPN, who did not follow the five rights of medication administration and relied on another LPN's identification of the resident. This error led to the resident experiencing emesis and being sent to the hospital for evaluation, although no negative outcomes were reported. The facility's policy on medication administration was not adhered to, resulting in the termination of the responsible LPN and the resignation of another involved LPN. Resident #86 did not receive several medications as ordered upon admission due to a failure to fax the orders to the pharmacy. This resulted in a delay in the administration of critical medications for conditions such as pain, hypertension, and diabetes. The error was discovered when the resident's family reported the missed medications to an LPN, who then faxed the orders to the pharmacy. Multiple staff members, including the admitting nurse and the previous DON, were involved in the oversight, but the medications were not administered until the following day or later. The facility's medication administration policy, which requires medications to be given within one hour of the ordered time, was not followed in both cases. Interviews with staff and review of records confirmed the lapses in protocol, leading to significant medication errors for both residents. The deficiencies were investigated under specific complaint numbers, highlighting the facility's non-compliance with medication administration standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Masury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Addison Healthcare Center | 0.8 mi | ★★★★★ | 7 | 0 |
| Clepper Manor | 1.8 mi | ★★★★★ | 0 | 0 |
| Hermitage Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 5 | 0 |
| Saint John Xxiii Home | 4.4 mi | ★★★★★ | 1 | 0 |
| Meadowbrook Manor | 5.5 mi | ★★★★★ | 8 | 0 |
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