Citations in Ohio
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Ohio.
Statistics for Ohio (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Ohio
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with multiple food items improperly labeled or stored, exposed and freezer-burned meat, and unsanitary equipment and fixtures. These deficiencies had the potential to affect all 104 residents in the facility.
Surveyors observed that the dumpster area was not maintained in a clean and sanitary condition, with significant debris such as used gloves, food containers, and a damaged cardboard box scattered around. The grease barrel was also left open with a stock pot of water on top. These conditions were confirmed by a dietary aide and had the potential to affect all 104 residents.
Multiple areas of the facility were found to be unclean or unsanitary, including a dining room with food debris, a laundry room with soot from a previous dryer fire, and a resident's room with a strong odor due to refusal to bathe. Staff confirmed delays in cleaning and repairs, and residents reported unaddressed maintenance issues.
The facility did not report an allegation of misappropriation involving possible forged signatures on narcotic logs for two cognitively intact residents receiving oxycodone. An LPN raised concerns to management, and the DON conducted an internal investigation, including drug testing of staff, but did not notify the State Agency as required by policy and regulation.
The facility did not fully investigate allegations of misappropriation involving two cognitively intact residents with orders for oxycodone. The DON confirmed that only face-to-face interviews with nurses were conducted, with no written statements or resident interviews documented, contrary to facility policy requiring comprehensive interviews and documentation.
Surveyors found that three residents' rooms had holes in the walls and torn wallpaper, with both residents and staff confirming the damage had not been addressed. Review of maintenance logs showed no documentation that these issues were identified or reported, despite facility procedures requiring staff to log such maintenance needs.
Surveyors found that the facility did not ensure clean food service areas and failed to label or date opened food items in storage, preparation, and refrigeration areas. Observations included undated dry goods, food residue on equipment, and unlabeled items in both the refrigerator and freezer, all of which were verified by the Administrator. Facility policies required labeling, dating, and regular sanitation, but these were not followed.
Staff served smaller portions of chicken and wild rice casserole than required by the facility's menu spreadsheet, using a four-ounce scoop instead of the specified eight-ounce serving. This resulted in at least one resident reporting hunger and requesting more food, and the issue was confirmed by dietary staff and management.
The facility did not serve meals in accordance with posted mealtimes and resident preferences, resulting in delayed meal delivery to multiple residents. Staff confirmed the delays and residents reported frequent late meal service, with observations showing trays delivered well after scheduled times. The deficiency affected several residents and had the potential to impact all who received meals from the kitchen.
Several dependent residents with cognitive and mobility impairments did not receive timely incontinence care or assistance with activities of daily living after activating their call lights. Staff were observed turning off call lights without providing care, and some residents' needs went unmet for extended periods. Facility policy required prompt response and completion of requested tasks before turning off call lights, but this was not consistently followed, as confirmed by resident interviews, staff statements, and electronic call light audits.
Deficient Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, labeling, and cleanliness. During an inspection, it was found that several food items in the walk-in cooler, including a spiral ham, chopped onion, diced turkey, butter, bacon bits, and beef fat, were either not labeled or not dated. In the walk-in freezer, beef slabs were left exposed on a cardboard box, showing significant freezer burn, and cookie dough bites were stored in an open plastic bag. These findings were confirmed by a dietary aide at the time of discovery. Further inspection of the kitchen revealed unsanitary conditions, including multiple light fixtures containing dust, debris, and dead bugs. The six-burner cooktop had a thick layer of black food buildup around and underneath the burners, and the microwave used for resident food was extremely dirty with brown residue. The facility's policy on food preparation and storage was reviewed and found to be undated, but it stated that food items should be kept free of harmful organisms and substances. The observed deficiencies had the potential to affect all 104 residents in the facility.
Improper Disposal and Sanitation of Dumpster Area
Penalty
Summary
The facility failed to maintain the dumpster area in a clean and sanitary condition, as observed during a survey with a dietary aide. Significant amounts of debris, including plastic gloves, used plastic silverware, paper plates with food residue, brown bags, and various plastic items were found scattered to the left of the dumpster. In front of the dumpster, a cardboard box was observed on the ground, appearing to have been run over multiple times by vehicles. To the right of the dumpster, the facility's grease barrel was found open to the air with a stock pot of water placed on top. These findings were confirmed by staff during the survey. This deficiency had the potential to affect all 104 residents residing in the facility, as noted in the facility census at the time of the survey.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary living environment, as evidenced by multiple observations and interviews. On one occasion, food, dirt, and dust were found in the first floor dining room during breakfast service, and two residents were told by a staff member that the dining room was closed, requiring them to eat in their rooms. In the main laundry room, black soot was observed on several ceiling tiles, a result of a dryer fire that had occurred approximately three months prior. The Housekeeping and Laundry Director confirmed the presence of soot and stated that replacement of affected items was pending insurance approval. Additionally, water damage was observed on two ceiling tiles above a resident's bed, and the resident reported that she had requested replacement but it had not yet occurred. Another deficiency was noted in a resident's room, which had a strong odor attributed to poor personal hygiene. Staff interviews confirmed that the resident was capable of bathing independently but consistently refused to do so, having only accepted one shower in the past three months. The strong odor in the room was acknowledged by both the LPN and CNA, who attributed it to the resident's refusal to bathe. These findings were substantiated through direct observation and staff and resident interviews.
Failure to Report Alleged Misappropriation of Resident Narcotics
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the State Agency as required by regulation and facility policy. Specifically, concerns were raised regarding the administration of oxycodone to two cognitively intact residents with complex medical histories, including conditions such as cerebral infarction, congestive heart failure, multiple sclerosis, and various psychiatric and pain disorders. An LPN reported to nursing management that another nurse may have been forging signatures on narcotic logs related to the administration of oxycodone for these residents. This concern was based on observations and reports from other nurses, including suspicions of signature forgery. Despite these allegations, the Director of Nursing (DON) confirmed that an internal investigation was conducted, which included requiring all nurses in the affected area to undergo drug testing. However, the DON did not consider the situation to be an allegation of misappropriation and therefore did not report it to the State Agency, as required by both facility policy and state regulations. The facility's policy clearly states that all incidents and allegations of misappropriation must be reported immediately to the administrator or designee and to the state department of health within two hours if abuse or serious bodily injury is alleged. The failure to report the incident constituted non-compliance with regulatory requirements.
Failure to Properly Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to fully investigate allegations of misappropriation involving two residents who were both cognitively intact and had physician orders for oxycodone for pain management. For one resident, the medical record showed an admission with multiple complex diagnoses, including dementia, heart failure, and chronic pain, while the other had a history of conditions such as antiphospholipid syndrome, depression, and fibromyalgia. Both residents had ongoing orders for oxycodone, and their Minimum Data Set assessments confirmed cognitive intactness at the time of the events. The Director of Nursing (DON) confirmed that an investigation was conducted regarding a nurse and the administration of narcotics, but no written statements were obtained from staff or residents. The DON stated that only face-to-face interviews were conducted with the nurses involved, and no documentation of interviews or statements from any potential resident victims was completed. This approach was not in accordance with the facility's policy, which requires interviews with the resident, the accused, and all witnesses, as well as documentation of the investigation. The lack of proper documentation and failure to interview residents directly led to the deficiency.
Failure to Maintain Resident Rooms Free of Damage
Penalty
Summary
Surveyors identified that the facility failed to maintain resident rooms in a safe and homelike condition, as evidenced by the presence of holes in the drywall and torn wallpaper in the rooms of three residents. Observations revealed that one resident's room had two large holes and torn wallpaper on the wall beside the bed, which the resident confirmed had been present for a long time. Another resident's room had a large hole and torn wallpaper behind the bed, with the resident acknowledging the damage but unsure of its duration. A third resident's room also had a hole and torn wallpaper behind the bed, though the resident was unaware of the damage. Staff interviews confirmed the existence of these deficiencies in all three rooms. A review of the facility's maintenance work order log from June to August did not show any documentation that the holes or torn wallpaper in these rooms had been identified or reported. The facility's work order process requires staff to identify and log maintenance needs, but there was no evidence that this process was followed for the affected rooms. The deficiency was identified during a complaint investigation and affected three out of four residents reviewed for a homelike environment, with the facility census at 47.
Failure to Maintain Food Service Sanitation and Labeling Standards
Penalty
Summary
Surveyors observed that the facility failed to maintain clean food service areas and did not properly label or date opened food items. During a kitchen tour, potato chips and white cake mix in the dry storage area were found without dates, and in the prep area, the slicer had dried food on the blade while the mixer had dried batter on the backsplash. In the reach-in refrigerator, bacon, chicken noodle soup, and lima beans were not labeled or dated, and in the reach-in freezer, breaded chicken patties, chicken fingers, unbreaded chicken breasts, onion rings, and French fries were also not labeled or dated. These findings were confirmed by the Administrator at the time of observation. Facility policies reviewed indicated that open packages and leftovers should be labeled and dated, and that kitchen sanitation should be maintained through compliance with a written cleaning schedule. Four residents were identified as receiving nothing by mouth (NPO), and the facility census was 86 at the time of the survey.
Failure to Serve Accurate Meal Portions According to Menu Requirements
Penalty
Summary
The facility failed to ensure that accurate portions were served according to the menu diet spreadsheet during meal service. Observations revealed that residents in the main dining room who were not on a pureed diet received less than the required portion of chicken and wild rice casserole. Specifically, the serving utensil used was a #8 scoop, which provided only four ounces, while the facility's spreadsheet indicated that the serving size should be one cup, or eight ounces, using either an eight-ounce spoodle or two four-ounce scoops. This discrepancy was confirmed by both dietary staff and the Mobile Dietary Manager during the observation. As a result of the insufficient portions, at least one resident reported feeling hungry and requested additional food. The deficiency affected 22 residents who were not on a pureed diet and had the potential to impact all residents receiving meals from the facility. The facility census at the time was 86, with additional residents identified as receiving pureed diets or being NPO. The findings were based on direct observation, interviews with residents and staff, and review of facility documentation.
Failure to Serve Meals Timely According to Resident Needs and Posted Mealtimes
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner according to posted mealtimes and resident preferences. Observations revealed that lunch trays were delivered late to certain halls, with one food cart leaving the kitchen 24 minutes after the scheduled time and meal trays being delivered to residents well past the posted mealtime. Staff interviews confirmed the delay, with one staff member stating they were unsure of the reason for the late meal service and had been asked to assist with passing trays. Residents also voiced concerns during a Resident Council meeting that meals were often served late. The deficiency affected at least three residents and had the potential to impact all residents receiving food from the kitchen. The facility census was 86, with four residents identified as NPO (nothing by mouth). Review of posted mealtimes indicated that the Middle Hall and Back Hall received their meal trays later than scheduled. The findings were based on observation, interview, and record review, and were investigated under two complaint numbers.
Failure to Provide Timely Incontinence Care and Call Light Response
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living for several dependent residents, as evidenced by record reviews, direct observations, interviews, and policy review. Multiple residents with significant medical conditions, including chronic kidney disease, cognitive impairment, limited mobility, and incontinence, were observed not receiving prompt care after activating their call lights. In one instance, a resident repeatedly called for help to be changed, but staff either turned off the call light without providing care or failed to respond for an extended period, despite the resident's continued requests and visible distress. Facility policy required that call lights not be turned off until the resident's needs were met, but this was not followed, and electronic call light audits showed a significant number of delayed responses. Additional observations revealed that other residents requiring moderate assistance for toileting and mobility also experienced delays in care. Staff were seen turning off call lights and leaving rooms without addressing residents' needs, and some staff were unaware of the specific requests made by residents. Interviews with residents confirmed that their needs were not met in a timely manner, and that staff often left after turning off the call light, sometimes not returning to provide the requested assistance. Staff interviews indicated a lack of awareness or adherence to the facility's call light response procedures. Further review of records showed that a resident's power of attorney had to contact the facility to report that the resident had not been checked or changed for several hours, contrary to the facility's policy of checking and changing every two hours. The incident was documented, and staff were reminded of the policy, but the deficiency was confirmed through interviews and documentation. Facility policies clearly outlined the expectation for timely response to call lights and incontinence care, but these were not consistently followed, resulting in unmet care needs for multiple residents.
Some of the Latest Corrective Actions taken by Facilities in Ohio
- Educated the MDS Coordinator on the fall management program covering individualized fall-prevention plans, timely care-plan updates after each fall, and physician notification requirements (J - F0689 - OH)
- Provided Administrator and DON training on comprehensive fall investigations encompassing risk-management documentation, witness interviews, root-cause analysis, care-plan updates, and post-fall IDT notes (J - F0689 - OH)
- Established a daily Monday-through-Friday clinical IDT review process for every fall event to conduct root-cause analyses, update care plans, and implement new interventions under DON oversight (J - F0689 - OH)
- Initiated monthly QAPI review of fall trends with the Medical Director to guide ongoing performance-improvement efforts (J - F0689 - OH)
- In-serviced all licensed nurses on fall-management protocols including completion of SBAR forms, incident reports, and detailed fall documentation (J - F0689 - OH)
Failure to Timely Assess, Investigate, and Intervene After Resident Falls
Penalty
Summary
The facility failed to timely assess and develop comprehensive care plans for residents with a history of falls prior to admission, and did not complete thorough fall investigations or implement timely and appropriate interventions for residents who experienced falls. This deficiency was identified through medical record reviews, hospital records, fall investigations, staff interviews, and policy reviews. Three residents with a history of falls were affected, with two residents suffering multiple falls within short periods, resulting in serious injuries such as closed head injuries, lumbar spine fractures, hematomas, rib fractures, humerus fracture, and acute blood loss anemia requiring hospitalization and blood transfusion. One resident was admitted with a history of falls and multiple risk factors, including metabolic encephalopathy, Parkinson’s disease, muscle weakness, and cognitive deficits. Despite being assessed as high risk for falls, the resident experienced four falls in eight days, with no new interventions added to the care plan after each event. Fall investigations were incomplete, lacking witness statements, environmental checks, and care plan updates. Another resident with repeated falls and minimal cognitive impairment also experienced multiple falls, including two that resulted in hospitalizations for significant injuries. The facility did not provide fall investigations or implement new interventions after these incidents, and there was insufficient documentation regarding the circumstances of the falls and whether existing interventions were in place at the time. A third resident with a history of falls prior to admission also experienced a fall in the facility, but the care plan was not updated and no fall investigation was completed. Staff interviews confirmed that fall investigations were not consistently performed, care plans were not updated with new interventions, and incident reports were sometimes missing. The facility’s fall management policy required individualized care plans, post-fall evaluations, and documentation of fall incidents, but these procedures were not followed for the affected residents.
Removal Plan
- Resident #88 was sent to the hospital and did not return to the facility.
- Resident #99 was sent to the hospital and did not return to the facility.
- The Administrator held a Quality Assurance and Performance Improvement (QAPI) meeting with the DON and Medical Director #910 to discuss the Immediate Jeopardy template and plan of removal.
- Regional Minimum Data Set (MDS) Coordinator #920 educated MDS Coordinator #100 regarding the facility’s fall management program which included an individualized fall prevention for each resident identified at risk and updating the care plan with each fall event to ensure new interventions are implemented appropriately and the physician is notified of each fall event.
- MDS Coordinator #100 reviewed the care plans of 13 residents who were currently active in the facility and had experienced a fall in the last 30 days to ensure adequate interventions are in place and care plans are up to date with interventions.
- RDCO #900 educated the Administrator and DON on completing thorough fall investigations to include completing risk management, conducting witness interviews if applicable, updating care plans with appropriate fall interventions, identifying root cause analysis, and post fall interdisciplinary notes (IDT) for all fall events.
- The clinical interdisciplinary team (IDT) will review all residents who experience a fall event during the next scheduled clinical IDT meeting which is held Monday through Friday. This meeting includes the Administrator, DON, Social Worker, and Director of Rehabilitation. The clinical IDT will complete a thorough post-fall investigation, including a root cause analysis (RCA) to determine contributing factors and intervention opportunities. The clinical IDT will ensure the individualized intervention opportunity is updated to reflect in the fall care plan with the goal of reducing the recurrence. The DON will champion the meeting and ensure compliance with documentation, investigation/RCA determination, care plan updates, and intervention implementation. Any identified concerns will result in immediate staff training and, if appropriate, progressive disciplinary action.
- The Administrator reviewed the facility’s Fall Management and Care Plan Revision policies. No changes were made. Fall trends will be brought to QAPI and reviewed monthly with Medical Director #910.
- The DON/Designee completed in-service training for all 22 licensed nursing staff focused on fall management. This included completing a fall Situation, Background, Assessment, and Recommendation (SBAR), incident report within the medical record and fall related details. Nurses are responsible for the direct care of the resident at the time of the fall.
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