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 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.
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.
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.
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.
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 implement required fall prevention interventions, failed to respond promptly to call lights, and did not provide the necessary level of staff assistance during transfers and care for several residents with cognitive and physical impairments. In multiple instances, residents were left unattended or transferred without the required two-person assistance, resulting in falls and injuries. Required post-fall assessments were also not completed for a resident who sustained minor injuries.
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.
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.
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 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.
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 Implement Fall Prevention and Safe Transfer Protocols
Penalty
Summary
The facility failed to ensure the safety of residents at risk for falls by not implementing care plan interventions, responding to call lights in a timely manner, and conducting timely intermittent observations. One resident with dementia and a history of repeated falls was not provided with required fall prevention measures such as Dycem under the mattress, and was left unattended for extended periods despite activating the call light and exhibiting restless behaviors. Video evidence showed the resident was not repositioned or checked on for several hours, resulting in multiple falls from bed. Staff also failed to use the mechanical lift with the required two-person assistance, as a hospice aide transferred the resident alone, contrary to physician orders and facility policy. Two other residents with quadriplegia and significant ADL needs were not provided with the required level of assistance during care. In both cases, a single CNA left the resident unattended while turned on their side during care, resulting in falls from bed. The care plans and Kardex for these residents specified the need for two-person assistance for mobility and toileting, but this was not followed. Staff interviews confirmed that only one aide was present during the incidents, and that the residents were dependent on staff for care due to their conditions. Additionally, the facility failed to complete required post-fall assessments for a resident who sustained minor injuries after a fall outside the building. Although the fall was witnessed and the resident was assessed for injuries, the pain assessment and fall assessment forms were not completed as required. These deficiencies were verified through record review, staff interviews, and facility policy review, affecting multiple residents with varying degrees of cognitive and physical impairment.
Some of the Latest Corrective Actions taken by Facilities in Ohio
- Updated the Narcotic Pain Patch Policy to mandate dual-nurse verification of patch placement at every shift change and dual-nurse removal/disposal with documentation in the controlled-substance log (J - F0760 - OH)
- Provided staff with a standardized list of approved patch-placement sites and abbreviations to ensure consistent and accurate documentation (J - F0760 - OH)
- Placed a reminder sheet in the narcotic log book directing nurses to physically verify fentanyl patch placement during each shift-change count (J - F0760 - OH)
- Delivered focused education on the revised narcotic pain-patch procedures covering physical checks, dual-nurse disposal, standardized abbreviations, and immediate reporting of missing patches (J - F0760 - OH)
- Educated facility leadership on risk-event reporting and investigation protocols to strengthen proactive identification and mitigation of medication errors (J - F0760 - OH)
Failure to Initiate CPR for Full Code Resident Due to Delayed Access to Advance Directives
Penalty
Summary
A deficiency occurred when staff failed to provide basic life support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was found unresponsive on the toilet, despite the resident's advance directive indicating full code status. Certified Nursing Assistants (CNAs) discovered the resident in distress and alerted an LPN, who assessed the resident and found no pulse. Instead of initiating immediate CPR, the LPN sought guidance from another LPN on a different floor, who then contacted the Unit Manager at home for advice on locating the resident's advance directives. During this time, the LPN was unable to quickly access the resident's code status due to difficulties finding the medical chart and lack of immediate computer access. The delay in action resulted in no CPR being performed while staff attempted to confirm the resident's code status. EMS was contacted and arrived to find the resident deceased, with rigor mortis and other signs of irreversible death present. EMS staff indicated it was too late for resuscitation efforts. The resident was left slumped over on the toilet until EMS arrived, and staff did not attempt to move the resident or initiate life-saving measures as required by the facility's policy and the resident's documented wishes. The resident involved had a history of cognitive, social, and emotional deficits following cerebrovascular disease, mild vascular dementia, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, polyosteoarthritis, and a previous myocardial infarction. The resident's physician orders and care plan clearly indicated a full code status, meaning all life-saving measures were to be used in a medical emergency. Despite this, the staff's failure to promptly initiate CPR and their inability to access the resident's advance directives in a timely manner directly contributed to the deficiency.
Removal Plan
- The Director of Nursing (DON) provided education on Advance Directives, location of advanced directives, change of condition, and immediate response of CPR to all staff.
- Training was verified by review of sign in sheets.
- The DON and Administrator interviewed and/or collected statements from all staff working at the time of the incident involving Resident #61.
- A whole house audit of all residents was completed by the Regional Director of Clinical Services (RDCS) verifying code status, care plans and signed Do Not Resuscitate (DNR) forms.
- The Human Resource Director reviewed all nursing staff files to verify cardiopulmonary resuscitation (CPR) certifications were valid.
- The RDCS verified all laptops on the units were accounted for and available for nursing access.
- The DON audited crash carts to ensure all equipment was in place.
- An ADHOC Quality Assurance and Performance Improvement (QAPI) meeting was completed to discuss Advance Directives for all residents and develop education pertaining to Advance Directives, location of advanced directives, change in condition, and immediate response of CPR.
- A second ADHOC QAPI meeting was held to discuss code status levels, staff response expectations, and implementation/adjustment of the corrective action plan.
- Staff received education on advanced directives, location of the advanced directives, immediate response of CPR and change in condition by the RDCS and DON, with completion verified via sign-in sheets and random staff interviews.
- The facility implemented a plan for the DON/Designee to conduct Code Blue drills and location of advance directives on alternating shifts.
- The facility implemented a plan for the Administrator/Designee to audit all deaths to ensure resident's advanced directives were honored per preference.
- The facility implemented a plan for the DON/Designee to conduct audits to ensure that residents' change in conditions were addressed.
- The facility implemented a plan for the DON/Designee to conduct audits to ensure each unit had a laptop for nursing access.
Failure to Prevent Significant Medication Error with Fentanyl Patch Administration
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and chronic pain, who had a physician's order for a Fentanyl transdermal patch, was administered a new Fentanyl patch without the removal of the previous one. The LPN responsible was unable to locate or remove the previously administered patch but proceeded to apply a new patch and did not report the missing patch at the time. This resulted in the resident wearing two Fentanyl patches simultaneously, which was not discovered until after the resident exhibited symptoms of overdose, including lethargy, inability to walk or sit upright, and drooling. The facility failed to accurately assess the resident when the change in condition was noted. The nurse who responded to the resident's altered state did not complete a head-to-toe assessment and was unaware that the resident was receiving Fentanyl. Emergency Medical Services were called, and upon their assessment, two Fentanyl patches were found on the resident, one of which was initially hidden under a blood pressure cuff. Narcan was administered, and the resident was transported to the hospital, where an accidental overdose was confirmed. Documentation and monitoring of Fentanyl patch placement were inconsistent and inaccurate in the days leading up to the incident. There were multiple instances where the location of the patch was incorrectly documented or not documented at all, and missing patches were not reported to the physician or nursing management. Staff interviews revealed a lack of standardized procedures for patch administration, removal, and documentation, as well as insufficient training and communication regarding controlled substance protocols. The facility did not initiate an incident investigation or implement immediate interventions following the discovery of the overdose.
Removal Plan
- The DON completed a skin sweep on Resident #86 to ensure there were no additional patches applied.
- The DON completed a review of Resident #86's care plan and verified to show chronic pain and potential side effects.
- The DON completed a skin sweep on a like resident (Resident #50) who had discontinued orders for Fentanyl patches. The DON verified there were no patches present.
- RNCC #302 educated the Administrator and DON on reporting risk events and initiating investigation and implementing interventions.
- The Narcotic Pain Patch Policy was updated to include: Both nurses, oncoming and off going to check placement and document in medication administration record at shift change, and removal of Fentanyl pain patch to be completed by two nurses and documented in the controlled substance/narcotic log with two nurses for disposal.
- The DON updated Resident #86's orders to include documentation of Fentanyl patch location.
- The DON updated Resident #86's order to check Fentanyl patch placement every shift to also include location observed.
- The DON provided a standard list of locations and abbreviations placed on the unit for staff reference to ensure correct abbreviation documentation.
- The DON placed a reminder sheet in the narcotic book for the nurses to physically go to check narcotic placement at shift change.
- The DON provided education on the narcotic pain patch policy to include: Checking patch physically during count and documenting in the record; disposal of patch with two nurses and to fold patch and dispose by flushing and both nurses to document on the controlled substances/narcotic log with both nurses signing the log; using the standard list of locations and abbreviations to ensure correct abbreviation of location of Fentanyl patch; and on call manager to be notified immediately if Fentanyl patch missing.
- A root cause analysis was completed by the Interdisciplinary Team (IDT) including Medical Director (MD) #102, the Administrator, the DON, Assistant Director of Nursing (ADON) #208, and RNCC #302 with an ad hoc QAPI meeting.
- Auditing includes DON or designee to review shift to shift count with physical checking of patch placement is completed, validating placement of patch to match the medical record once daily for two weeks, then four times a week for four weeks.
- Auditing to include DON or designee to audit removal of Fentanyl patch to be with two nurses and documented accurately in the narcotic log daily for two weeks, then four times a week for four weeks.
- The DON provided education to LPN #242 on completing head-to-toe assessments.
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