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 facility failed to consistently monitor and document food temperatures and keep food covered during meal service. Review of temperature logs with the Dietary Manager showed that temperatures were recorded for only a small number of meals over several weeks, with many required meal times lacking any documentation. During an observed lunch in a satellite kitchen, food arrived from the main kitchen, was placed on a steam table at maximum heat, and remained uncovered until service began, while no temperatures were taken or recorded despite a thermometer being available. Staff acknowledged they did not check temperatures on arrival and were unsure if the food was held at safe temperatures, and the Dietary Manager confirmed that policy required temperatures to be taken and documented before serving and that food should remain covered.
The facility did not timely update resident trust account records, causing multiple accounts to show negative balances that staff acknowledged did not reflect actual resident funds. Fourteen residents with various chronic conditions, including dementia, schizophrenia, depression, COPD, and DM, were affected, with negative balances ranging from small amounts to over one thousand dollars. Staff interviews revealed that the Business Office Manager relied on the Executive Director to provide information on cashed checks and cost-of-care payments, and both the Administrator and Executive Director admitted they were behind on bookkeeping and documentation. Facility policies allowed residents or their representatives to request account balances and detailed fund activity, but the delayed updates meant the financial records were not accurate at the time of review.
Surveyors observed that the facility did not follow its approved menus and diet spreadsheets for multiple residents on reduced concentrated sweets (RCS) and pureed diets. Several residents with type 2 DM, morbid obesity, CKD, severe protein-calorie malnutrition, dementia, Parkinson’s disease, COPD, and dysphagia, who were ordered RCS or RCS mechanical soft diets, were served white or chocolate cake with frosting or fruit shortcake instead of the chilled peaches specified for RCS diets. Residents on pureed diets, whose menu called for pureed fruit shortcake, were instead given vanilla pudding because the cook had not prepared the pureed dessert. A nurse supervisor acknowledged that menus were not always followed and that diabetic residents received desserts they should not have, while dietary staff and the RD confirmed that the RCS and puree spreadsheets should have been followed and that the desserts served were not appropriate for the ordered diets.
The facility failed to follow its abuse and neglect policy by not reporting to the state agency or documenting an investigation after an Activity Assistant submitted written allegations that two CNAs verbally mistreated and neglected toileting needs of two cognitively impaired residents on a dementia unit. One resident with severe cognitive impairment, incontinence, and dependence for ADLs reportedly requested to use the restroom repeatedly over about an hour while a CNA, occupied with her phone, told her to wait despite her repeated statements that she would soil herself. Another resident with Alzheimer’s disease and severe cognitive impairment was reportedly yelled at on multiple occasions, publicly told it was acceptable to void in a brief instead of being taken to the bathroom, and subjected to a distressing incident in which a CNA threw her stuffed dog and joked that it had grown wings. These events were not documented in the medical records and were not reported or investigated as required.
The facility failed to promptly report, investigate, and document serious allegations that two residents with severe cognitive impairment and total dependence for ADLs were denied timely toileting and subjected to demeaning and bullying behavior by CNAs. An activity assistant reported that one resident was repeatedly refused access to the bathroom and told it was acceptable to use her brief in front of others, and that another resident was made to wait for an hour to toilet while a CNA remained on her phone, despite the resident’s repeated statements that she would soil herself. The assistant also described CNAs yelling at a resident, speaking to her in a demeaning tone, and intentionally distressing her by mishandling a stuffed dog she believed was real. Despite these written allegations, leadership acknowledged that no formal investigation was completed, the state agency was not notified, the accused staff were not removed from duty as required by policy, and there was no related documentation in the residents’ medical records.
A resident with severe cognitive impairment and multiple chronic conditions, including vascular dementia, COPD, and CKD, had incomplete and inaccurate medical records. Over a 12‑month period, there were no psychiatric evaluations or notes documented, and there was no record that the VA psychiatric physician was consulted about pharmacy recommendations or medications ordered by the facility physician, including psychotropics. The DON confirmed that although several telehealth meetings occurred between the resident, the spouse, facility staff, and the VA physician, there was no documentation of these encounters or any recommendations made.
A resident with dementia, incontinence, mobility deficits, and multiple comorbidities developed a coccyx Stage II pressure ulcer that progressively worsened to an unstageable ulcer with necrotic tissue. Although the care plan and facility policy called for monitoring skin changes, notifying clinical staff, weekly skin assessments, barrier cream use, dietitian involvement, and wound specialist management, the record showed no reassessment of the resident’s condition or investigation of the ulcer’s source as it enlarged and deteriorated. Documentation lacked evidence of nutritional assessment or support, mechanical pressure relief devices, or off-loading strategies being implemented, and later wound specialist recommendations for pressure redistribution and nutrition monitoring were not promptly documented as carried out.
Surveyors found multiple food storage and labeling deficiencies in the kitchen and walk-in refrigerator, including loose flour in a dirty bin, open cereal and taco shells without dates, and several opened refrigerated items such as cheese, salad mix, deli meats, boiled eggs, and sliced ham that were undated, improperly sealed, or visibly spoiled. Additional issues included unlabeled containers with unknown brown and white-clear liquids and food stored in a metal pan containing an unknown red liquid. Dietary staff acknowledged that facility policy requires opened and leftover foods to be covered, labeled, dated, and properly sealed, and confirmed that some items were likely expired and that the storage conditions were not acceptable.
Multiple residents with complex medical and psychiatric conditions had discontinued medications, including analgesics, antipsychotics, antibiotics, antiemetics, muscle relaxants, and other drugs, that were later discovered in the home of a former LPN. A Board of Pharmacy investigation linked these medications to the facility and found that they had been removed after discontinuation and resident discharge or transfer. The investigation also identified inconsistent and incomplete medication documentation, pre‑signed shift‑to‑shift narcotic counts, and a lack of any reliable method to verify that discontinued non‑narcotic medications were actually placed into pharmacy return bags, resulting in misappropriation of residents’ medications.
Staff failed to follow infection control practices when administering medications and performing blood glucose monitoring. An LPN placed multiple medications directly into her bare hand before giving them to a resident with cognitive impairment, and another LPN handled medications in her bare hand for two cognitively intact residents, without hand hygiene or gloves. For a resident with diabetes and peripheral vascular disease, an LPN carried a blood glucose meter by hand after use and stored it in the medication cart without disinfecting it, and reported never cleaning meters since starting work. Facility policies required that staff not touch medications when opening dose packs and that glucose meters be disinfected with a high-level antimicrobial product, and leadership confirmed that medications should not be placed in staff hands and that meters should be sanitized between residents.
Failure to Monitor and Document Safe Food Temperatures and Maintain Food Coverage During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure food was stored and served in a safe and sanitary manner, as required by its own Food Storage and Handling policy. Review of food temperature logs from 01/10/26 through 02/26/26 with the Dietary Manager (DM) showed that temperatures were recorded for only a limited number of meals on specific dates, while all other required meal service times lacked documented food temperatures. In an interview, the DM confirmed that kitchen staff did not routinely check food temperatures as required and that she could not provide consistent daily food temperature logs for each meal. During observation of a lunch meal service in the satellite kitchen, food arrived from the main kitchen and was placed on a steam table set at maximum heat, but no temperature log was present. The food remained uncovered for the duration of the observation period until service began, and although a thermometer was available and briefly handled by a staff member, no food temperatures were taken or documented. In interviews, staff in the satellite kitchen confirmed that no food temperatures were taken upon arrival from the main kitchen prior to meal service and stated they were unsure whether the food had been held at safe temperatures. The DM later confirmed that food temperatures should be taken upon arrival and prior to meal service and that food should remain covered, consistent with the facility’s written policy requiring temperature checks and documentation before serving.
Untimely Resident Trust Account Updates Result in Inaccurate Negative Balances
Penalty
Summary
The facility failed to properly hold, secure, and manage residents' personal funds by not keeping resident trust account financial records timely updated, resulting in multiple accounts showing negative balances. Fourteen residents' financial records were reviewed, and each showed a negative balance as of 02/27/26, despite facility leadership stating that most of these residents did not actually have negative balances. The residents involved had a range of medical diagnoses, including hypertension, dementia, schizophrenia, major depressive disorder, COPD, diabetes, and other chronic conditions, and several had documented cognitive impairments ranging from mild to severe, while others were cognitively intact. Specific review of each resident's trust account information dated 02/27/26 revealed negative balances varying in amount. One resident had a negative balance of -$970.99, another had -$31.45, and others had negative balances such as -$59.09, -$77.14, -$110.97, -$31.57, -$56.96, -$44.47, -$4.73, -$18.97, -$64.57, -$39.72, and -$36.71. One resident's account showed a significantly larger negative balance of -$1,819.10. These negative balances were documented for residents with differing cognitive statuses, including residents whose MDS assessments showed severe cognitive impairment, mild cognitive impairment, intact cognition, and some whose cognitive status had not yet been evaluated. Interviews with facility staff confirmed that the negative balances were largely due to delays and backlogs in bookkeeping and updating of financial records, rather than actual overspending by residents. The Business Office Manager stated that many resident financial records were not up to date and that she depended on the Executive Director to provide information about cashed checks and cost-of-care payments before she could update the accounts. The Administrator acknowledged that the facility was behind in paperwork and bookkeeping, resulting in resident financial records reflecting negative balances that did not correspond to the residents' true financial status. The Executive Director confirmed he could fall behind on documenting resident financial expenses and revenues and that most residents with negative balances did not truly have negative balances because the records had not yet been updated. Facility policies stated that residents are permitted to manage their personal funds or, if managed by the facility, to receive quarterly statements and to obtain their account balances and written breakdowns of fund activity upon request, underscoring the requirement for accurate and timely financial recordkeeping that was not being met.
Failure to Follow Therapeutic Diet Menus and Spreadsheets for RCS and Pureed Diets
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and the approved menu/spreadsheet for residents, particularly those on reduced concentrated sweets (RCS) and pureed diets. Surveyors observed the lunch tray line and found that multiple residents with orders for RCS diets, including those with morbid obesity, type 2 diabetes mellitus, chronic kidney disease, and severe protein-calorie malnutrition, were served high-sugar desserts that were inconsistent with their diet orders and the facility’s RCS policy. For several cognitively intact or moderately impaired residents who required setup or cleanup assistance and were care planned as being at nutritional risk, tray tickets specified chilled peaches as the dessert for RCS diets, yet staff placed large portions of white cake with cherry topping and whipped topping on their trays. Fruit was available and had been placed on other residents’ trays, but was not used for these RCS diet trays. Additional observations showed that residents on RCS mechanical soft diets were also served inappropriate desserts. Residents with diagnoses including type 2 diabetes with neuropathy, dementia, Parkinson’s disease, COPD, and dysphagia, and who were ordered RCS, no salt packet, mechanical soft diets, received chocolate cake with white frosting or fruit shortcake. The tray tickets for these residents indicated RCS mechanical soft diets, and in at least one case specified fruit shortcake, but the facility’s RCS spreadsheet indicated that RCS diets should receive chilled peaches instead of fruit shortcake. The registered dietitian and dietary technician later confirmed that chocolate cake with icing and fruit shortcake were not appropriate dessert choices for residents on RCS mechanical soft diets and that a glitch in the tray card system meant there was no spreadsheet breakdown for combination diets such as RCS mechanical soft. Surveyors also identified that the facility did not follow the puree diet spreadsheet for residents ordered pureed texture diets. The facility’s fall and winter menu and corresponding spreadsheet specified that residents on pureed diets were to receive pureed fish of the day, pureed vegetables, pureed dinner roll with margarine, and pureed fruit shortcake for lunch. However, during observation of the tray line, no pureed fruit shortcake was present, and residents on pureed diets were instead given small plastic bowls of vanilla pudding. The dietary director confirmed that the cook had not prepared the pureed fruit shortcake and that these residents were therefore receiving vanilla pudding in place of the menu-specified dessert. A registered dietitian and dietary technician confirmed that the spreadsheets needed to be followed and that residents on pureed diets should have received pureed fruit shortcake. The facility’s own policies on RCS diets and on menus and adequate nutrition required that meals be prepared consistent with RCS guidelines and that menus be followed, but these were not adhered to during the observed meal service. A registered nurse supervisor acknowledged during interview that menus were not always followed and stated that diabetic residents were receiving desserts they should not be getting, noting that everybody got cake for lunch that day. Across the cited examples, residents’ medical records consistently showed therapeutic diet orders, MDS assessments documenting therapeutic or mechanically altered diets, and care plans identifying nutritional risk with interventions to provide diet and fluids as ordered and to honor preferences as able. Despite this, the lunch service on the observed day did not follow the written menus, diet spreadsheets, or physician orders for RCS and pureed diets, resulting in desserts being served that were inconsistent with the residents’ prescribed diets and the facility’s written policies.
Failure to Report and Investigate Allegations of Neglect and Verbal Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of resident neglect to the state agency and to document an investigation, as required by its abuse and neglect policy. The facility’s policy dated 2016 states that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injuries of unknown source must be immediately reported to the administrator or designee, and that the administrator or designee will notify the state survey agency of all such alleged violations within 24 hours of the allegation being made known to staff. Despite this policy, the Human Resources Director acknowledged that written allegations submitted by an Activity Assistant regarding staff treatment of residents on the dementia unit were not reported to the state agency and that no written investigation was completed. Resident #2, admitted on 10/28/25, had diagnoses including type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, parosmia, and hypertension. The most recent MDS showed severe cognitive impairment, no behaviors, dependence for all ADLs including toileting, frequent incontinence, and risk for pressure ulcer without current skin breakdown. Progress notes from October 2025 through February 2026 contained no documentation of alleged incidents. In the Activity Assistant’s written statement, she reported that Resident #2, while seated at a table with other residents, repeatedly stated she needed to use the restroom over the course of about an hour. CNA #401 was assisting another resident, and CNA #400, who was on her phone, repeatedly told Resident #2 she had to wait, while Resident #2 repeatedly said she was going to soil herself and needed the bathroom immediately. Resident #3, admitted on 09/01/25, had diagnoses including Alzheimer’s disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder. The MDS indicated severe cognitive impairment, behaviors directed at others, dependence on staff for ADLs, bladder incontinence, bowel continence, and risk for pressure ulcer development with no current skin breakdown. The Activity Assistant’s statement described multiple occasions where CNA #400 raised her voice at Resident #3, including telling her she was not allowed to speak to people a certain way and that she needed to apologize, and later yelling at her to be quiet from down the hall. On another occasion, when Resident #3 requested to use the restroom about 45 minutes after a prior toileting, CNA #400 questioned her in a demeaning tone, delayed responding for 5–10 minutes, then refused to take her when the lunch cart arrived, telling her in front of others that it was acceptable because she was wearing a brief. The statement also described CNA #400 and CNA #401 recounting as a joke an incident where CNA #401 threw Resident #3’s stuffed dog in front of her, telling her the dog grew wings, which caused the resident distress. These allegations were not documented in the residents’ progress notes, not reported to the state agency, and not formally investigated by the facility.
Failure to Investigate and Report Allegations of Neglect and Disrespectful Care
Penalty
Summary
The deficiency involves the facility’s failure to promptly act on and thoroughly investigate allegations of neglect and disrespectful treatment toward two cognitively impaired residents on the dementia unit. Resident #2, admitted with multiple diagnoses including type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, and hypertension, had a recent MDS showing severe cognitive impairment, dependence for all ADLs including toileting, frequent incontinence, and risk for pressure ulcers without current skin breakdown. Resident #3, admitted with Alzheimer’s disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder, had an MDS indicating severe cognitive impairment, behaviors directed at others, dependence for ADLs, bladder incontinence, bowel continence, and risk for pressure ulcer development without current skin breakdown. Progress notes for both residents from October 2025 through February 2026 contained no documentation of any alleged incidents related to neglect or mistreatment. According to a written statement dated 12/03/25 from Activity Assistant #300, CNA #400 repeatedly raised her voice at Resident #3, including telling the resident she was not allowed to speak to people a certain way and that she needed to apologize, and later yelling at her to be quiet while the resident was in her room. On another occasion, Resident #3 requested to use the restroom about 45 minutes after a prior toileting; CNA #400 responded in a demeaning tone, questioned whether the resident would actually go, and repeatedly told her to “hold on.” After five to ten minutes of continued requests, when the lunch cart arrived, CNA #400 told Resident #3 she could not be taken to the bathroom because it was lunch time and stated in front of others that it was okay because the resident was wearing a brief, leaving the resident clearly upset. AA #300 also reported that CNA #400 and CNA #401 recounted, as if humorous, an incident where CNA #401 took Resident #3’s stuffed dog (which the resident considers real), threw it in front of her, and told her the dog grew wings, causing the resident distress. AA #300 stated Resident #3 was regularly targeted and subjected to bullying and neglectful treatment. AA #300 further reported that a few weeks prior, Resident #2, who was seated at a table with other residents, announced she needed to use the restroom. CNA #401 was assisting another resident, and CNA #400 told Resident #2 they would help her soon. Over the next hour, Resident #2 repeatedly asked to use the restroom while CNA #400, who was on her phone, continued to tell her she had to wait; Resident #2 repeatedly stated she was going to defecate in her pants and needed to go to the bathroom immediately. Despite these allegations, the Human Resources Director confirmed that when AA #300 submitted the written allegations on 12/03/25, no investigation was documented, the state survey agency was not notified, and the accused CNAs were not removed from the facility but instead reassigned to a different unit. This response was inconsistent with the facility’s Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, which requires immediate reporting to the administrator, notification of the state agency within 24 hours, removal of accused staff from the facility pending investigation, completion of an investigation within five working days, and documentation of resident assessment and notifications in the medical record.
Failure to Maintain Complete and Accurate Psychiatric and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple chronic conditions, including type II diabetes, hydrocephalus, vascular dementia, COPD, chronic kidney disease, and a severe cognitive impairment documented on an MDS assessment. Review of this resident’s medical record showed no psychiatric evaluations or notes regarding psychiatric meetings for the previous 12 months, despite the resident receiving psychiatric care through the VA. There was no documentation that the VA psychiatric physician was consulted or informed of pharmacy recommendations related to the resident’s ordered medications, including psychotropic medications, nor any documentation that the VA psychiatric physician was consulted about medications ordered by the facility physician. During an interview, the DON confirmed there was no documentation in the resident’s record to support psychiatric appointments or meetings with the VA physician. She acknowledged that telehealth meetings involving the resident, his wife, facility staff, and the VA physician had occurred on three separate dates, but the facility had no documentation of these encounters, including what was discussed or any recommendations made regarding the resident’s health. This lack of documentation resulted in incomplete and inaccurate medical records for the resident.
Failure to Reassess and Intervene as Pressure Ulcer Progressed to Unstageable
Penalty
Summary
The deficiency involves the facility’s failure to implement and adjust interventions to prevent a pressure ulcer from worsening in a resident who was initially assessed as low risk for pressure ulcer development. The resident had multiple diagnoses including dementia, Alzheimer’s disease, autonomic neuropathy, edema, and incontinence, and was dependent on staff for most activities of daily living. The care plan in place identified the resident as at risk for pressure ulcer development due to cognitive impairment, incontinence, mobility and balance deficits, weak gait, decreased activity, and medications affecting sensory perception. Planned interventions included monitoring and documenting skin changes, notifying appropriate clinical staff of new breakdown, weekly skin assessments, use of barrier cream, dietitian assessment for nutritional needs, and management by a wound specialist center. On a documented date, a CNA notified an RN that the resident had an open area on the coccyx, which the RN assessed as a Stage II pressure ulcer. Barrier cream was applied, and the wound care nurse was to assess the resident. The initial wound documentation described a small Stage II ulcer with scant serosanguinous drainage and epithelial tissue. A nursing plan of care was then developed to address the coccyx skin alteration, including topical treatments such as triad paste and chamosyn with honey. However, there was no evidence in the medical record of any reassessment of the resident’s overall condition or investigation into the source of the pressure ulcer at that time, and no nutritional interventions or evaluations were documented despite the resident’s identified risk for malnutrition. Subsequent weekly wound documentation showed that the coccyx pressure ulcer progressively increased in size and changed in tissue characteristics over several weeks. The ulcer measurements increased from 1 cm by 1.5 cm by 0.1 cm to 2.0 cm by 1.5 cm by 0.1 cm, with the development of slough tissue, and eventually to 3.0 cm by 4.0 cm by 2.0 cm with foul odor and moderate necrotic tissue, at which point it was assessed as an unstageable pressure ulcer. Throughout this period of worsening, the record lacked evidence of reassessment of the resident’s condition in response to the ulcer’s progression, lacked documentation of efforts to identify the possible source of pressure, and did not show implementation of mechanical pressure relief devices, off-loading strategies, or nutritional support and evaluation. Although a wound specialist later evaluated the ulcer and made recommendations including an air pressure mattress, repositioning, frequent incontinence checks, and nutritional monitoring, the medical record did not show that these recommendations were promptly implemented, and there continued to be no documented additional interventions for mechanical off-loading or nutritional evaluation. The facility’s own skin care and pressure management policy stated that any new pressure ulcer should trigger reevaluation of the prevention plan and interventions, but the infection preventionist/wound care nurse confirmed there was no documentation that the facility attempted to determine the origin of the ulcer or implement nutritional interventions as required by the care plan and policy. The deficiency affected one resident out of three reviewed for pressure ulcer prevention and wound healing, in a facility with a census of 89 residents. The resident’s Minimum Data Set assessment had identified severely impaired cognition, rejection of care on some days, dependence on staff for ADLs, always incontinent of bowel and bladder, and an in-house acquired unstageable pressure ulcer. Despite these identified risks and the facility’s policy requirements, the medical record showed that the facility did not reassess the resident’s condition or modify interventions in response to the development and worsening of the pressure ulcer, and did not complete nutritional assessments or implement nutritional support after the ulcer was first identified.
Improper Food Storage, Labeling, and Sanitation in Kitchen and Walk-In Refrigerator
Penalty
Summary
Surveyors identified a failure to store and label food in a sanitary manner in the facility kitchen, potentially affecting all 74 residents who consumed food prepared there. In the dry storage room, a large amount of loose flour was found lying in the bottom of a plastic bin on a shelf, and three open bags of corn flakes were observed without dates indicating when they had been opened. Soft taco shells were stored in plastic storage bags that were not labeled with dates opened. A dietary employee confirmed that all opened foods were required to be labeled with the date opened and acknowledged that the flour bin needed to be cleaned out. Inside the walk-in refrigerator, surveyors observed multiple improperly stored and apparently spoiled food items. An opened bag of shredded mozzarella cheese lay on a shelf with the top corner unsealed, no date opened, and a light red substance around the opening. An opened bag of salad mix was not closed or sealed, and some lettuce inside was light brown, wilted, and slimy. An open package of sliced hickory-smoked turkey breast, stored in a plastic bag, was dated as opened 42 days earlier, and an open package of thick-sliced bologna, also in a plastic bag, was dated as opened 47 days earlier. Two plastic bags containing peeled boiled eggs and sliced ham that was yellow and slimy were undated and were lying in the bottom of a metal pan containing an unknown thick red liquid. A plastic beverage pitcher with a brown, thick substance and a small plastic cup with a white plastic lid containing a thin white-clear fluid were both unlabeled. A dietary employee confirmed that foods should be dated when opened or prepared, that the dated bologna and turkey were likely expired, that the cup appeared to contain separated spoiled milk, that the metal pan needed to be cleaned and should not have had food lying in it, and that opened food packages should be properly closed or sealed. Facility policy required food to be stored in clean, dry, uncontaminated areas, at appropriate temperatures, covered, labeled, and dated, with leftovers used within seven days or discarded.
Misappropriation of Discontinued Resident Medications and Inadequate Medication Control
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from misappropriation of their medications, which are considered the residents’ belongings. Ten residents had medications that were later found in the home of a former LPN who had worked part‑time at the facility. These residents had various diagnoses including paranoid schizophrenia, Alzheimer’s disease, bipolar and schizoaffective disorders, COPD, diabetes, osteoarthritis, paraplegia, end‑stage renal disease, and anxiety disorders. Their treatment regimens included antipsychotics, antidepressants, antianxiety agents, anticonvulsants, opioids, antibiotics, antiplatelet agents, hypoglycemics, and other medications such as ibuprofen, quetiapine, ondansetron, hydroxyzine, olanzapine, cyproheptadine, ampicillin, gabapentin, metronidazole, and baclofen. The Ohio Board of Pharmacy and law enforcement identified probable drug diversion by an LPN who had worked at the facility. After the LPN’s death from an overdose of prescription drugs, medications labeled for ten different residents from the facility were found at the LPN’s residence. These included ibuprofen 600 mg and 800 mg, quetiapine 100 mg, ondansetron 4 mg, hydroxyzine 25 mg, olanzapine 10 mg, cyproheptadine 4 mg, ampicillin 500 mg, metronidazole 500 mg, baclofen 10 mg, and an empty blister pack of gabapentin 300 mg. The medications had been discontinued at the facility, and the Board of Pharmacy determined they had been removed from the facility after discontinuation and after residents were discharged or transferred. During the Board of Pharmacy’s inspection of the facility, multiple documentation and control issues were identified that related to the handling and security of medications. Signatures on controlled drug documentation were inconsistent, with variations in initials and full names, and some shift‑to‑shift narcotic counts were pre‑signed by the off‑going nurse. Documentation on medication cards or sheets did not always match the actual count, and some shift‑to‑shift counts were missing dates, signatures, and counts. Facility staff, including the Regional Director of Clinical Operations and an LPN, explained that when non‑narcotic medications were discontinued, nurses were expected to remove them from the medication cart and place them in a pharmacy return bag, but there was no method to verify that this actually occurred. The facility’s own abuse, neglect, and misappropriation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent, and the findings showed that discontinued resident medications were not adequately secured or tracked, allowing them to be wrongfully removed and found in the former employee’s home.
Failure to Sanitize Glucose Meters and Maintain Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to blood glucose monitoring and medication administration. One resident with diabetes and peripheral vascular disease required blood glucose monitoring; after this resident’s blood glucose level was checked, the LPN carried the blood glucose meter in her hand and then placed it in the top drawer of the medication cart without sanitizing it. The LPN stated she did not clean the meters between residents, was unsure how to clean them, and reported that she had worked at the facility for three weeks without ever cleaning the meters. Manufacturer guidelines for the meter indicated it should be cleaned and disinfected with an EPA-registered disinfectant detergent or germicide wipe, and the facility’s policy required glucose meters to be disinfected with a high-level antimicrobial wipe. The facility also failed to follow infection control standards during medication administration for three residents with various diagnoses including Alzheimer’s disease, heart failure, diabetes mellitus, schizoaffective disorder, depressive type, and chronic obstructive pulmonary disease. During observations, one LPN placed multiple medications directly into her bare hand without sanitizing or wearing gloves before administering them to a resident with impaired cognition, and another LPN placed medications into her bare hand without sanitizing or wearing gloves when administering to two residents with intact cognition. Both LPNs confirmed these practices during interviews, with one acknowledging she should have worn gloves before touching medications. The Regional Director of Clinical Operations confirmed that staff should not be popping medications into their hands and that blood glucose meters should be sanitized between each resident. Facility policy on medication administration stated that staff are not to touch medications when opening liquid or dose packs. The census at the time was 170 residents, and the deficiency was identified incidentally during a complaint investigation.
Some of the Latest Corrective Actions taken by Facilities in Ohio
- Educated all staff on the dementia clinical protocol and resident-check/behavioral monitoring process (including routine checks, behavioral assessment, interventions, monitoring, and the facility’s system change for sexually inappropriate residents such as pre-admission IDT review, care planning, psychiatric follow-up, immediate notification to nursing management/psychiatric team, and immediate placement on every 15-minute checks and/or one-to-one observation until deemed safe) (J - F0744 - OH)
- Implemented a system change for identifying and managing sexually inappropriate behaviors by requiring pre-admission IDT review for sexual behaviors, care planning for residents with dementia or cognitively intact residents with sexually inappropriate behaviors, psychiatric follow-up, immediate notification to nursing management and the psychiatric team, and immediate increased supervision (every 15-minute checks and/or one-to-one) until deemed safe (J - F0744 - OH)
- Established weekly IDT review using a new audit tool at standard-of-care meetings to ensure residents with diagnosed or identified sexual behaviors were identified and had interventions in place, with ongoing continuation of the system change (J - F0744 - OH)
- Implemented ongoing weekly review of at-risk residents with changes prompting team discussion and a plan of action (J - F0744 - OH)
Failure to Provide Adequate Behavioral Health Services and Supervision for Residents With Dementia and Sexual Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with dementia and known histories of sexually inappropriate behaviors received adequate and effective behavioral health services, individualized interventions, monitoring, and supervision. One resident with moderately impaired cognition and a long history of sexually inappropriate behaviors had multiple documented incidents over several months, including oral sex with another resident, encouraging a male resident to rub her legs, kissing a male resident in her room, being observed with a male resident’s hands in her pants, repeatedly entering male residents’ rooms, and speaking in explicit sexual detail to her roommate. Her guardian repeatedly expressed concerns and requested increased safety measures, including a transfer to an all-female facility. The resident’s care plan included intermittent periods of one-to-one observation and every 15‑minute checks, but these heightened monitoring interventions were repeatedly started and then resolved, and the 15‑minute checks were discontinued in October without documented rationale or authorization from the psychiatric provider. Another resident with severely impaired cognition and dementia also had a documented history of sexually inappropriate behaviors. His care plan identified sexually inappropriate behavior after an encounter with another resident and included interventions such as behavioral health services, medication management, and one-to-one observation if sexually inappropriate behavior occurred. He was prescribed cimetidine (Tagamet) off-label to reduce sexual desire. Nursing notes documented multiple episodes of him touching himself inappropriately in common areas and being redirected to his room, as well as reports from his sister about sexually inappropriate behaviors at his offsite day program and concerns about the effectiveness of his medication. Despite these ongoing behaviors and concerns, after his room was changed to a secured unit due to inappropriate touching of a female resident, there was no documented evidence of increased monitoring, reassessment, or new interventions between the time of the move and the subsequent incident. The deficiency culminated when the resident with severely impaired cognition and the resident with moderately impaired cognition, both with known sexually inappropriate behaviors, were placed on the same secured unit without reassessment or revision of their behavioral health care plans related to monitoring and supervision. Direct care staff expressed concerns about moving the male resident with sexually inappropriate behaviors to a unit where residents were generally less cognitively aware and more vulnerable, but these concerns were either not communicated to management or not acted upon. No increased monitoring or individualized behavioral interventions were implemented for either resident after the room change. Several days later, staff discovered the two residents in the female resident’s bedroom with both residents partially undressed and engaged in sexual intercourse, confirming that the facility had not provided the necessary behavioral health services, individualized interventions, and supervision required by their conditions and histories. The facility’s own policies on dementia care and behavior assessment required the interdisciplinary team to identify resident-centered care plans, evaluate behavioral symptoms for safety risk, monitor for worsening symptoms, and adjust interventions based on changes in behavior and needs. However, the residents’ ongoing sexually inappropriate behaviors, repeated incidents, guardian concerns, and changes in placement were not accompanied by consistent reassessment, documentation, or adjustment of monitoring and supervision. The psychiatric mental health nurse practitioner reported she was not informed of continued sexually inappropriate behaviors after the male resident’s room change and did not authorize discontinuation of the female resident’s 15‑minute checks, indicating a breakdown in communication and failure to follow established behavioral health protocols that contributed directly to the incident.
Removal Plan
- The DON, Certified Nurse Practitioner (CNP) #900, and Resident #05's guardian were notified of the sexual incident with Resident #10; full body skin assessments were completed for Resident #05 and Resident #10.
- Resident #10's guardian was notified by the facility of the sexual incident with Resident #05; the facility requested permission to transfer Resident #10 out of the facility later that day.
- The facility submitted an initial SRI with an allegation of sexual abuse to the State Survey Agency regarding the incident between Resident #05 and Resident #10.
- Resident #05 and Resident #10 were visited and evaluated by Psychiatric Mental Health Nurse Practitioner (PMHNP) #905.
- Resident #05 was sent to the hospital for further medical evaluation and sexually transmitted disease and hepatitis screenings.
- Resident #10 was discharged to another facility.
- Resident #05 was discharged to another facility.
- MDS Nurse #273, ADON #339, and Wound Nurse #354 interviewed all residents with a BIMS score of 13 and above about inappropriate sexual encounters, reporting, and safety; all residents with a BIMS score of 12 and below had a skin assessment completed to identify any possible changes.
- MDS Nurse #273, ADON #339, and Wound Nurse #354 completed behavior assessments for all residents in the facility.
- RDO #490 and Corporate Quality Assurance Nurse (CQAN) #467 educated all staff on the facility dementia clinical protocol, resident routine checks, behavioral assessment, intervention, and monitoring, and the facility system change for sexually inappropriate residents (including pre-admission IDT review for sexual behaviors; care planning for residents with dementia or cognitively intact residents with sexual inappropriate behaviors; psychiatric follow-up; immediate notification to nursing management and psychiatric team; immediate placement on every 15-minute checks and/or one-to-one observation until deemed safe).
- ADON #339 and Regional Nurse #255 reviewed the last 72 hours of resident charting to identify documentation of sexual behaviors; five residents (#60, #61, #63, #64, and #65) were placed on every 15-minute checks for inappropriate comments to staff; orders and notifications were completed; direct care staff would complete observations with management completing checks if changes were needed; IDT/psychiatric/physician would determine discontinuation; at-risk residents would be reviewed weekly with changes prompting team discussion and plan of action.
- MDS Nurse #273 reviewed and confirmed all residents with sexual behaviors had care plans in place with appropriate interventions.
- An ad hoc QAPI meeting was held to review the system change for sexually inappropriate residents and education provided to staff (including Medical Director, Activities Director, HRD, Social Services Assistant, Regional Nurse, MDS Nurse, Receptionist, Wound Nurse, and CQAN).
- The facility created an audit tool to be reviewed weekly at standard of care meetings with the IDT to ensure residents were identified and interventions were in place; residents with a diagnosis of sexual behavior or any sexual behavior identified would be audited weekly; the system change would continue ongoing.
- The DON or designee would audit behavior documentation five times a week for four weeks to ensure interventions were in place.
- The medical records for Residents #60, #61, #63, #64, and #65 were reviewed and verified care plans were in place with acceptable interventions for inappropriate sexual behaviors and confirmed each resident was under the care of PMHNP #905.
- Direct staff members were observed providing adequate surveillance for Residents #60, #61, #63, #64, and #65 with no issues noted.
- Interviews with RN #191, LPN #504, and CNA #141 verified staff were educated regarding dementia clinical protocol, resident routine checks, and behavioral assessment/intervention/monitoring, and were knowledgeable of residents requiring increased surveillance and the procedure for resident checks.
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