Inspection Reports for
Majestic Care Middletown Assisted Living
6898 HAMILTON-MIDDLETOWN ROAD, MIDDLETOWN, OH, 45042
Back to Facility ProfileCitations (last 4 years)
Citations (over 4 years)
16.5 citations/year
Citations are regulatory findings recorded during state inspections.
259% worse than Ohio average
Ohio average: 4.6 citations/yearCitations per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Census: 148
Citations: 6
Date: Jun 5, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding multiple deficiencies including environmental safety, resident care, medication management, food storage, infection control, and hand hygiene practices.
Complaint Details
This deficiency report represents non-compliance investigated under Complaint Number OH00164818.
Findings
The facility was found to have multiple deficiencies including damaged ceiling tiles in resident rooms, failure to provide nail care, delayed ordering of PRN Narcan, improper labeling and storage of insulin vials, unsanitary food storage areas, lack of a Legionella prevention program, and failure of staff to follow proper hand hygiene and glove use during incontinence care.
Citations (6)
F 0584: The facility failed to ensure a safe, functional, and homelike environment due to damaged, discolored, and missing ceiling tiles in rooms of Residents #54, #81, and #116.
F 0677: The facility failed to provide nail care for Residents #32 and #100, whose fingernails were long, jagged, and dirty.
F 0756: The facility failed to timely order PRN Narcan for Resident #135 despite pharmacy recommendations due to opioid and benzodiazepine use.
F 0761: The facility failed to ensure insulin vials and pen-injectors were properly labeled and dated when removed from refrigerated storage for Residents #23, #29, and #128.
F 0812: The facility failed to maintain clean food storage areas and properly store food, affecting multiple residents including Resident #36 whose refrigerator contained spilled juice and dead bugs.
F 0880: The facility failed to implement a Legionella prevention program and staff failed to change gloves and wash hands appropriately during incontinence care for Resident #97.
Report Facts
Facility census: 148
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 8
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #541 | Certified Nursing Assistant | Failed to change gloves and wash hands appropriately during incontinence care for Resident #97 |
| LPN #521 | Licensed Practical Nurse | Observed insulin vials not dated when removed from refrigerator |
| Maintenance Director #510 | Maintenance Director | Verified damaged ceiling tiles in resident rooms |
| Director of Nursing | Director of Nursing | Verified nail care deficiencies and insulin labeling issues |
| Consulting Pharmacist #900 | Consulting Pharmacist | Verified insulin vial labeling requirements |
| Dietary Manager #610 | Dietary Manager | Confirmed unsanitary food storage observations |
| Certified Nursing Assistant #513 | Certified Nursing Assistant | Verified unsanitary refrigerator in Resident #36's room |
| Maintenance Supervisor #496 | Maintenance Supervisor | Confirmed no Legionella prevention plan implemented |
| Administrator | Administrator | Confirmed no Legionella prevention plan implemented |
Inspection Report
Complaint Investigation
Census: 128
Citations: 1
Date: Feb 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the care provided to a resident with a colostomy.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00161868.
Findings
The facility failed to provide appropriate and adequate colostomy care for Resident #10, resulting in frequent leaking of the colostomy pouch and a rash caused by gastric juices contacting the skin. Staff interviews and observations confirmed ongoing issues with timely pouch changes and documentation of the rash.
Citations (1)
F 0691: The facility failed to provide appropriate colostomy care for Resident #10, resulting in frequent leaking of the colostomy pouch and a rash on the resident's abdomen. Staff did not always replace the colostomy pouch timely, and documentation of the rash was inconsistent.
Report Facts
Residents Affected: 1
Census: 128
Days with loose stool or diarrhea: 18
Admission date: Jan 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #17 | Reported concerns about timely emptying of Resident #10's colostomy pouch and confirmed rash observation | |
| Certified Nurse Aide (CNA) #20 | Acknowledged Resident #10's colostomy bag leaked often and rash was present | |
| Director of Nursing (DON) | Observed Resident #10's colostomy and rash, acknowledged issues with appliance fit and documentation | |
| Wound Nurse (WN) #22 | Observed rash caused by gastric juices and noted improper appliance fitting | |
| Licensed Practical Nurse (LPN) #26 | Reported ongoing colostomy leaking and rash for Resident #10 |
Inspection Report
Complaint Investigation
Census: 134
Citations: 1
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to reasonably accommodate the needs and preferences of residents, specifically related to accessibility and protection from weather in the outdoor smoking area.
Complaint Details
This deficiency represents non-compliance investigated under Master Complaint Number OH00161683.
Findings
The facility failed to ensure the outdoor smoking area was reasonably accessible and protected from weather, affecting one resident directly and potentially 26 others. The door to the smoking area was manual and difficult to open, lacked automatic openers or communication devices for assistance, and the canopy was removed for colder months, leaving no weather protection.
Citations (1)
F 0558: The facility failed to reasonably accommodate the needs and preferences of residents by not providing an accessible door or communication devices for assistance in the outdoor smoking area. The smoking area lacked weather protection as the canopy was removed during colder months.
Report Facts
Facility census: 134
Residents smoking: 33
Residents affected: 26
Residents reviewed for accommodation: 3
Inspection Report
Complaint Investigation
Census: 35
Citations: 4
Date: Jan 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding failure to notify a resident's representative of a change in health care status and other related compliance issues.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Numbers OH00160511 and OH00161077.
Findings
The facility failed to notify a resident's representative of a significant change in condition, failed to complete required care conferences, failed to follow physician orders for medication administration resulting in medication errors, and failed to implement infection control policies during medication administration.
Citations (4)
F 0580: The facility failed to notify Resident #137's representative of a significant change in health status and new physician orders. Documentation was silent for family notification until hospital transfer.
F 0657: The facility failed to complete required care conferences for Resident #137, with only one care conference held during the review period despite policy requiring quarterly meetings.
F 0760: The facility failed to follow physician orders for Resident #37's medication administration, administering Midodrine despite blood pressure readings outside ordered parameters.
F 0880: The facility failed to implement infection control during medication administration when an LPN dropped a pill on the floor, picked it up, and administered it to Resident #114.
Report Facts
Facility census: 35
Facility census: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Verified medication administration errors and care conference deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Verified family notification was delayed for Resident #137 |
| LPN #129 | Licensed Practical Nurse | Observed dropping and administering a pill that was picked up from the floor |
Inspection Report
Complaint Investigation
Census: 142
Citations: 3
Date: May 29, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify physicians of significant weight changes and wound treatment refusals, inadequate incontinence care, and failure to provide palatable meals at appropriate temperatures.
Complaint Details
This deficiency represents non-compliance investigated under Master Complaint Number OH00154225 and Complaint Number OH00153635, and includes continued non-compliance from prior surveys dated 02/14/24 and 04/29/24.
Findings
The facility failed to notify physicians or nurse practitioners of significant weight loss and wound treatment refusals, failed to provide timely and adequate incontinence care and follow physician orders for incontinence products, and failed to provide residents with palatable meals at safe and appetizing temperatures. These issues affected multiple residents and represented continued non-compliance from previous surveys.
Citations (3)
F 0580: The facility failed to notify the physician or nurse practitioner of significant weight changes and wound treatment refusals for residents as ordered.
F 0690: The facility failed to perform timely and adequate incontinence care and did not follow physician orders for use of incontinence products for several residents.
F 0804: The facility failed to provide residents with palatable meals served at appropriate temperatures, resulting in residents receiving cold food and not eating adequately.
Report Facts
Facility census: 142
Weight loss percentage: 18.39
Food temperatures: 121
Food temperatures: 110
Food temperatures: 60.2
Food temperatures: 60.3
Food temperatures: 43.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #306 | Licensed Practical Nurse | Confirmed Resident #108 refused wound treatments and physician was not notified |
| Unit Manager LPN #335 | Unit Manager Licensed Practical Nurse | Confirmed NP was not notified of Resident #108's wound treatment refusals and staff put brief on Resident #108 against physician order |
| Regional Nurse Consultant #320 | Regional Nurse Consultant | Confirmed physician was not notified of Resident #26's significant weight loss |
| State Tested Nurse Aide #342 | State Tested Nurse Aide | Confirmed incontinence care was not done timely for residents |
| Licensed Practical Nurse #340 | Licensed Practical Nurse | Confirmed incontinence care was not completed as required and Resident #108 wore brief against physician order |
| Licensed Practical Nurse #355 | Licensed Practical Nurse | Confirmed residents remained wet and peri-care was not completed |
| State Tested Nurse Aide #321 | State Tested Nurse Aide | Confirmed incontinence care rounds frequency and incomplete care |
| Account Manager Healthcare Services #401 | Account Manager Healthcare Services | Confirmed food and milk temperatures were not at appropriate levels to serve |
Inspection Report
Complaint Investigation
Census: 138
Citations: 3
Date: Apr 29, 2024
Visit Reason
The inspection was conducted in response to complaints regarding failure to notify physicians of medication shortages, prevention of physical abuse, and failure to provide appropriate dialysis care and services.
Complaint Details
The complaint investigation involved allegations of failure to notify physicians of medication shortages, failure to prevent physical abuse, and failure to provide appropriate dialysis care. The investigation substantiated these issues, including an incident of physical abuse involving Resident #65 and a staff member, and the death of Resident #06 due to missed dialysis treatments.
Findings
The facility failed to notify physicians of medication shortages affecting Resident #65, failed to prevent physical abuse involving Resident #65 and staff, and failed to ensure Resident #06 received scheduled dialysis treatments, resulting in immediate jeopardy and the resident's death. Additional residents receiving dialysis lacked proper communication and documentation.
Citations (3)
F 0580: The facility failed to notify the physician when medications were unavailable due to a national shortage, affecting Resident #65 who missed doses of Mounjaro on three dates.
F 0600: The facility failed to prevent physical abuse involving Resident #65 and RN #100, including verbal altercations and physical resistance, resulting in staff suspension and resignation.
F 0698: The facility failed to provide safe, appropriate dialysis care for Resident #06, who missed two dialysis treatments leading to cardiopulmonary arrest and death. The facility also failed to maintain communication and documentation for other residents receiving dialysis.
Report Facts
Residents affected: 1
Residents affected: 1
Residents reviewed for dialysis: 5
Missed dialysis treatments: 2
Census: 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #100 | Registered Nurse | Involved in physical abuse incident with Resident #65; resigned after suspension |
| LPN #303 | Licensed Practical Nurse | Failed to communicate rescheduled dialysis appointment for Resident #06; resigned |
| UM #302 | Unit Manager | Failed to communicate dialysis appointment and orders for Resident #06; terminated |
| STNA #130 | State Tested Nursing Assistant | Reported physical abuse incident involving Resident #65 and RN #100 |
| STNA #304 | State Tested Nursing Aide | Reported Resident #06 was still in facility when dialysis center called |
| DON | Director of Nursing | Confirmed findings related to medication shortage, abuse, and dialysis care |
| RNC #200 | Regional Nurse Consultant | Confirmed findings related to medication shortage, abuse, and dialysis care |
| NNP #300 | Nephrologist Nurse Practitioner | Provided medical oversight and confirmed risks of missed dialysis for Resident #06 |
| NP #307 | Nurse Practitioner | Notified of missed dialysis treatments for Resident #06 |
Inspection Report
Complaint Investigation
Census: 145
Citations: 8
Date: Mar 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation into multiple allegations of non-compliance related to resident care, medication access, staff competencies, infection control, and vaccination administration at the nursing facility.
Complaint Details
The inspection was conducted under multiple complaint numbers including OH00151159, OH00151161, OH00151871, OH00151239, and OH00151329. The complaints involved issues with preadmission screening, care conferences, fall prevention, nutritional care, staff training, medication access, infection control, and vaccination administration.
Findings
The facility was found non-compliant in several areas including failure to complete preadmission screening, incomplete quarterly care conferences, inadequate supervision leading to resident falls, failure to meet residents' nutritional needs, insufficient staff training for ventilator care, inability to access medications from the electronic dispenser, improper use of personal protective equipment, and delayed influenza vaccination administration.
Citations (8)
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities was not completed prior to admission for one resident, resulting in admission despite a denial of nursing facility services.
F 0657 The facility failed to ensure quarterly care conferences were completed for five residents, with missing documentation for scheduled conferences.
F 0689 The facility failed to provide adequate supervision to prevent a resident fall resulting in fractures and failed to supervise a resident who smoked, placing him at risk.
F 0692 The facility failed to ensure residents' nutritional needs were met as care planned, with significant unaddressed weight loss or gain and lack of physician notification.
F 0726 The facility failed to ensure nursing staff had the competencies and skill set to care for residents on ventilators, with inadequate training and no documented skills checkoffs.
F 0755 The facility failed to ensure staff could access medications from the electronic medication dispenser, delaying administration of comfort medications to a resident.
F 0880 The facility failed to ensure staff used appropriate personal protective equipment while in a resident's isolation room, exposing others to infection risk.
F 0883 The facility failed to administer influenza vaccine timely to a resident despite earlier consent, delaying vaccination until months later.
Report Facts
Facility census: 145
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 5
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #17 | Licensed Practical Nurse | Reported lack of formal training and skills checkoff for ventilator care |
| LPN #115 | Licensed Practical Nurse | Reported insufficient training and discomfort working on ventilator unit |
| STNA #03 | State Tested Nursing Assistant | Left resident unassisted leading to fall |
| STNA #31 | State Tested Nursing Assistant | Provided care to resident prior to fall |
| Infection Preventionist #91 | Infection Preventionist | Confirmed PPE noncompliance and training gaps |
| Regional Nurse Consultant #59 | Regional Nurse Consultant | Confirmed lack of training policy for new employees |
| Director of Nursing (DON) | Director of Nursing | Involved in medication access issue and communication with Hospice |
| Hospice Clinical Director #195 | Hospice Clinical Director | Provided information on medication access delay and investigation |
| Director of Quality #190 | Pharmacy Director of Quality | Provided information on Ebox access code issues |
Inspection Report
Complaint Investigation
Census: 147
Citations: 4
Date: Feb 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to failure to timely notify physicians of abnormal laboratory results and failure to provide timely incontinence care.
Complaint Details
The deficiencies represent non-compliance under Complaint Numbers OH00150450 and OH00150126 related to delayed notification of abnormal lab results and inadequate incontinence care.
Findings
The facility failed to notify physicians timely of abnormal lab results for residents, resulting in delayed treatment for urinary tract infections and C-diff infections. Additionally, the facility failed to provide timely incontinence care to residents, affecting their hygiene and comfort.
Citations (4)
F 0580: The facility failed to notify the physician of abnormal laboratory results in a timely manner, resulting in delayed treatment for two residents' urinary tract infections and C-diff infections.
F 0677: The facility failed to ensure residents received timely incontinence care, affecting two residents who were frequently incontinent and not checked regularly.
F 0684: The facility failed to timely notify the physician of abnormal laboratory results for a resident's positive C-diff, resulting in delayed treatment.
F 0690: The facility failed to notify the physician of abnormal laboratory results timely, delaying treatment for a resident's urinary tract infection.
Report Facts
Facility census: 147
Residents affected: 2
Residents affected: 2
Residents reviewed: 4
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Clinical Nurse #128 | Regional Clinical Nurse | Acknowledged late notification of positive urinalysis and C-diff results |
| Physician #119 | Physician | Reported no provider was notified of Resident #162's positive C-diff results |
| Licensed Practical Nurse #105 | Licensed Practical Nurse | Observed saturated incontinence brief and assisted Resident #20 |
| State Tested Nursing Assistant #129 | State Tested Nursing Assistant | Reported checking Resident #20 prior to breakfast and noted slight wetness |
| State Tested Nursing Assistant #109 | State Tested Nursing Assistant | Observed leaving Resident #154's room with soiled linens and verified first check of shift |
Inspection Report
Complaint Investigation
Census: 160
Citations: 4
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure medications administered intravenously were obtained from a source with a valid Terminal Distributor of Dangerous Drugs (TDDD) license specific to the State of Ohio.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00148164.
Findings
The facility failed to ensure that IV medications were obtained from a properly licensed source, affecting multiple residents. The contracted ancillary provider lacked the required Ohio TDDD licensure, and facility staff improperly signed off on medication administration they did not perform.
Citations (4)
F 0694: The facility failed to ensure medications administered intravenously were obtained from a source with a valid Ohio Terminal Distributor of Dangerous Drugs (TDDD) license. This affected four reviewed residents and potentially many others.
F 0755: The facility failed to ensure medications were obtained from a source with a valid Ohio TDDD license for contracted ancillary provider services affecting multiple residents.
F 0837: The facility failed to ensure a contracted entity had appropriate Ohio credentials for provision of services, affecting multiple residents.
F 0842: The facility failed to ensure medication administration was signed off by appropriate staff, with licensed practical nurses signing off on IV medications they did not administer.
Report Facts
Residents affected: 4
Current residents affected: 23
Discharged residents affected: 18
Census: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #313 | Licensed Practical Nurse | Signed off on IV medication administration not performed |
| LPN #411 | Licensed Practical Nurse | Signed off on IV medication administration not performed |
| Representative #405 | Ancillary provider representative who stated they did not have Ohio TDDD licensure | |
| General Counsel #406 | General Counsel | Provided information about licensure issues and contract approval process |
| Medical Director | Medical Director | Discussed introduction of ancillary IV infusion service and lack of involvement in provider agreement |
| RN #409 | Registered Nurse | Contracted RN who provided education to facility nurses about IV medication administration |
| RN #410 | Registered Nurse | Contracted RN who provided education to facility nurses about IV medication administration |
Inspection Report
Complaint Investigation
Census: 177
Citations: 2
Date: Aug 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00145592 to assess the facility's compliance with care planned fall interventions, safety measures, and timely incontinence care.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00145592.
Findings
The facility failed to ensure care planned fall interventions were in place for residents at risk of falls, failed to maintain safety measures such as non-skid strips and call light accessibility, and failed to provide timely incontinence care to a resident. These deficiencies affected multiple residents and were confirmed by observations and staff interviews.
Citations (2)
F 0689: The facility failed to ensure care planned fall interventions were implemented for residents at risk of falls. Two residents reviewed did not have required elevated perimeter mattresses or safety measures such as non-skid strips and call light accessibility in place.
F 0690: The facility failed to provide timely incontinence care to a resident, resulting in the resident being observed saturated with urine and soiled bedding. Documentation showed the resident was last changed hours earlier than observed.
Report Facts
Residents affected: 2
Residents affected: 1
Census: 177
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Tested Nursing Aide (STNA) #185 | Interviewed confirming missing elevated perimeter mattress and incontinence care issues | |
| Licensed Practical Nurse (LPN) #266 | Interviewed confirming fall intervention measures were not in place |
Inspection Report
Routine
Census: 173
Citations: 15
Date: Mar 29, 2023
Visit Reason
Routine inspection of Majestic Care of Middletown LLC to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident financial management, notification of fund balances, environmental safety and cleanliness, abuse reporting and investigation, PASARR screening, discharge summary documentation, personal care, activity provision, podiatry and dental services, nutrition and food service safety, and therapy services documentation.
Citations (15)
F 0567: Facility failed to ensure residents had written authorizations for the facility to manage their personal funds, affecting two residents.
F 0569: Facility failed to notify residents when their personal funds balance approached the social security income resource limit, affecting two residents.
F 0584: Facility failed to maintain a clean and safe homelike environment in resident rooms and dining areas, affecting six residents.
F 0609: Facility failed to timely report suspected abuse and misappropriation of resident property to the State Agency, affecting one resident.
F 0610: Facility failed to thoroughly investigate a potential incident of misappropriation of resident property, affecting one resident.
F 0645: Facility failed to complete a preadmission screening resident review (PASARR) for a resident with an expired hospital exemption and history of mental illness.
F 0661: Facility failed to ensure a discharge summary was completed and provided to a resident upon discharge.
F 0677: Facility failed to ensure female residents received regular shaving of chin hairs, affecting two residents.
F 0679: Facility failed to provide activities consistent with residents' interests, affecting two residents.
F 0687: Facility failed to ensure podiatry services were provided as ordered, affecting one resident.
F 0692: Facility failed to obtain daily and weekly weights upon admission and as ordered for three residents.
F 0791: Facility failed to ensure a dental appointment was scheduled for tooth extractions for one resident.
F 0803: Facility failed to provide food portions as planned by a Registered Dietitian and failed to adhere to fluid restrictions for one resident.
F 0812: Facility failed to store, serve, and prepare food in a sanitary manner and failed to monitor refrigerator and dishwasher temperatures properly.
F 0825: Facility failed to accurately document a resident's weight bearing status and assess the need for therapy services after an orthopedic appointment.
Report Facts
Facility census: 173
Residents affected: 2
Residents affected: 2
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 5
Residents affected: 167
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #29 | Licensed Practical Nurse | Reported missing wedding ring to Unit Manager |
| LPN Unit Manager #64 | Licensed Practical Nurse Unit Manager | Received report of missing wedding ring and conducted limited investigation |
| Administrator | Interviewed about missing wedding ring and reporting procedures | |
| Assistant Business Office Manager #169 | Assistant Business Office Manager | Verified residents lacked written authorization for fund management and notification of fund balances |
| STNA #33 | State Tested Nursing Assistant | Verified dirty room conditions |
| Licensed Practical Nurse #81 | Licensed Practical Nurse | Verified dirty room conditions |
| Maintenance Assistant #142 | Maintenance Assistant | Verified environmental deficiencies and lack of repairs |
| Housekeeping Supervisor #1 | Housekeeping Supervisor | Reported staffing and cleaning issues |
| Activity Director #152 | Activity Director | Reported staffing shortages affecting activities |
| Dietary Aide #209 | Dietary Aide | Observed food handling violations |
| Account Manager #208 | Account Manager | Reported food portion discrepancies and kitchen sanitation issues |
| Registered Dietitian #138 | Registered Dietitian | Verified missing weights and dietary fluid restrictions |
| Director of Nursing | Director of Nursing | Verified missing weights and discharge documentation |
| Director of Rehab #750 | Director of Rehabilitation | Reported lack of notification for therapy needs after orthopedic appointment |
Inspection Report
Complaint Investigation
Census: 173
Citations: 8
Date: Mar 29, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to maintain a clean and safe homelike environment for residents.
Complaint Details
This deficiency substantiates Complaint Number OH00141421.
Findings
The facility failed to maintain a clean and safe environment in the main dining room and resident rooms, including broken furniture, dirty floors, trash accumulation, and a leaking ceiling. These conditions affected six residents and had the potential to affect all residents.
Citations (8)
F 0584: The facility failed to maintain a safe and homelike environment. Resident #145's bed footboard was cracked with jagged edges, the nightstand door was missing, and there was a hole in the wall that remained unrepaired.
Resident #10's room had a dirty floor, trash in the room, dirty linens on the bed, and trash on the floor and dresser.
Resident #144's room had a dirty floor with multiple stains and trash in bags on the floor near the bathroom door.
Resident #163's room had a dirty floor, strong urine smell, trash on the floor, dirty linens on the bed, and open food items on the dresser.
Resident #21's room had a dirty floor, dirty linens, trash on the floor and dresser, and a personal refrigerator containing foul-smelling food with white fuzz.
Resident #131's room had a dirty floor with large yellow stains under the bed.
Resident #151's room had a dirty floor, clutter on a supply stand, trash in the room, and dirty linens on the bed.
The dining room ceiling was leaking water, creating a large puddle approximately 2 feet round with wet floor signs around it.
Report Facts
Facility census: 173
Hole size in bed footboard: 4
Hole size in wall: 6
Puddle diameter: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #84 | Verified observations of broken bed footboard, nightstand door, and wall hole | |
| Maintenance Assistant #142 | Verified bed board, nightstand, and wall hole were not reported and needed repair | |
| State Tested Nursing Assistant (STNA) #33 | Verified condition of multiple residents' rooms | |
| Licensed Practical Nurse (LPN) #81 | Verified condition of Resident #21's room | |
| State Tested Nursing Assistant (STNA) #37 | Verified condition of Resident #131 and #151's rooms | |
| Activity Director | Verified ceiling leak in dining room | |
| Housekeeping Supervisor (HS) #1 | Provided information about housekeeping schedules and issues with leaky ceiling |
Inspection Report
Complaint Investigation
Census: 171
Citations: 7
Date: Jul 11, 2019
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to provide required Medicare Non-Coverage notices, failure to implement abuse policies, failure to timely report abuse, failure to respond appropriately to alleged violations, failure to provide assistance with activities of daily living, failure to timely obtain hearing services, and improper labeling of drugs and biologicals.
Complaint Details
The visit was complaint-related, triggered by allegations including failure to provide Medicare Non-Coverage notices, failure to implement and report abuse policies, failure to provide adequate ADL assistance, failure to obtain hearing services, and improper medication labeling. The allegations were substantiated as the facility failed in these areas.
Findings
The facility failed to provide required Medicare Non-Coverage notices to discharged residents, failed to implement and report allegations of sexual abuse properly, failed to provide adequate assistance with activities of daily living including showers, failed to timely obtain hearing services for a resident, and failed to properly label opened medications and biologicals. These deficiencies affected multiple residents and posed minimal harm or potential for actual harm.
Citations (7)
F 0582: The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) when Medicare Part A residents were discharged home with skilled days remaining.
F 0607: The facility failed to implement their abuse policy regarding an allegation of sexual abuse between two residents, including failure to investigate and create a self-reported incident.
F 0609: The facility failed to timely report an allegation of sexual abuse to the Ohio Department of Health.
F 0610: The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents.
F 0677: The facility failed to provide assistance with activities of daily living, including showers, for two residents as per their care plans.
F 0685: The facility failed to timely obtain hearing services for one resident who was hard of hearing and lacked hearing aids or headphones.
F 0761: The facility failed to properly label opened drugs and biologicals, including undated vials of Tuberculin PPD and multiple undated inhalers for four residents.
Report Facts
Facility census: 171
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #218 | Registered Nurse | Witnessed and reported sexual abuse incident involving residents #16 and #35 |
| Unit Manager/LPN #119 | Licensed Practical Nurse | Interviewed regarding sexual abuse incident and did not consider it sexual abuse |
| Assistant Administrator #6 | Assistant Administrator | Interviewed regarding NOMNC notices, sexual abuse incident, and shower refusals |
| Director of Nursing | Director of Nursing | Investigated sexual abuse incident and determined it was not sexual abuse |
| STNA #87 | State Tested Nursing Assistant | Reported on resident hearing and shower care |
| RN #213 | Registered Nurse | Verified undated medications and reported communication with resident #80 |
| LPN #171 | Licensed Practical Nurse | Verified undated inhaler for resident #97 |
| LPN #151 | Licensed Practical Nurse | Verified undated inhaler for resident #115 and discussed shower refusals |
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