Shawnee Estates Senior Living — Ohio Facility Report

Inspections on file

Deficiencies cited

Visits with none

Substandard care

Immediate jeopardy

The most recent inspection on file for Shawnee Estates Senior Living took place on May 28, 2026. Across the 12 inspections published by the Ohio Department of Health, surveyors cited 9 deficiencies.

A deficiency is a rule the surveyor found the facility was not meeting. Ohio inspects against two rule books at once, so most findings carry a federal code and an Ohio code for the same problem; each is counted once here, the way the state counts it. Correction dates are the state's confirmation that the issue was fixed.

This report reproduces what Ohio publishes and nothing else. Of the 12 inspections listed, the state publishes the surveyor's written findings for 5; for the other 7 it publishes only the date, the type of visit and the number of deficiencies - 7 of which found none.

Facility Details

Ohio license number

#2217R

County

Greene

Administrator

Zondra Compton

Director of nursing

Summer Howard

Phone

(937) 372-1530

Ownership

For Profit - Corporation

Inspections

12 on file · 9 deficiencies

May 28, 2026Licensure survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

December 2, 2025Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

August 25, 2025Complaint survey1 deficiency▼

R-0680Maintain building and groundsOhio citation · correction confirmed 10/08/2025▼

What the surveyor found

Based on observations, record review, and interviews the facility failed to maintain a clean, safe, and sanitary environment for the residents. This affected two residents (Resident #51 and Resident #70) reviewed for lack of housekeeping services. This had the potential to affect all residents in the facility. The facility census was 68.

Findings include:

1. Observation on 08/25/25 at 9:10 A.M. of empty resident room 210 revealed multiple dead bugs found on the floor in the living area, bathroom and shower. A large spider suspended in a web was observed hanging from the kitchen counter.

2. Observation on 08/25/25 at 10:00 A.M. of Resident #51's room revealed dead bugs and spider webs in the corners of the room. A brown substance was observed dried to the floor underneath the back leg of the chair. The floor was observed to be covered in crumbs and debris. Four ant traps were observed in the room: one under a chair, one under the bed, one behind the dresser, and one behind the television stand. Upon observation of the bathroom, the toilet seat and toilet lid had dried brown smears on both surfaces.

Interview on 08/25/25 at 10:50 A.M. with Caregiver #133 confirmed the dead bugs and spider webs in the corners of the room, a brown substance was observed dried to the floor underneath the back leg of the chair, the floor was was covered in crumbs and debris, and the toilet seat and toilet lid had dried brown smears on both surfaces in Resident #51's room and bathroom.

Review of the housekeeping check off documentation dated 08/03/25 to 08/24/25 revealed Resident #51's room was serviced on 08/06/25 and documented caregivers called me to the room to clean up poop in the bathroom. The only items marked off were clean toilet and sweep/mop floor in bathroom, the remaining items including resident room and other bathroom items were not addressed this visit. Resident #51's room was cleaned on 08/12/25 and stated as best as possible for now will do more tomorrow. Facility did not have any documentation of evidence resident's room cleaning was followed up on the next day. Resident #51's room was cleaned on 08/19/25 and stated shower and floors need time to clean better. There was no description why floors were unable to be thoroughly cleaned on this visit.

3. Observation on 08/25/25 at 10:05 A.M. revealed multiple dead bugs on the floor and cobwebs reaching up the side of the wall with dead bugs suspended in them in a common area of the memory care unit.

Interview on 08/25/25 at 11:08 A.M. with Caregiver #133 confirmed there were multiple dead bugs on the floor and cobwebs reaching up the side of the wall with dead bugs suspended in them in a common area of the memory care unit in the common area of the memory care unit.

4. Observation on 08/25/25 at 10:33 A.M. of Resident #70's room revealed dust bunnies, crumbs, and a piece of chocolate candy on the floor in the room and under the bed. Upon observation of the bathroom, dead bugs were observed in the shower stall and the inside of the toilet bowl was smeared with feces. The window was observed to be open to air with no screen.

Interview on 08/25/25 at 11:04 A.M. with Caregiver #133 confirmed there were dust bunnies, crumbs, and a piece of chocolate candy on the floor in the room and under the bed, the window was open to air with no screen, dead bugs in the shower stall, and the inside of the toilet bowl was smeared with feces in Resident #70's room and bathroom.

Review of housekeeping documentation dated 08/03/25 to 08/24/25 revealed Resident #70's room was cleaned on 08/07/25, 08/14/25, and 08/21/25 and all three visits was documented that Resident #70 was in the room and was only swept. Due to resident being in bed, the floors were not mopped and sheets were not changed. Facility provided no evidence of any follow up of Resident #70's room being mopped at a later time that day of on another day.

Review of the pest control invoices and receipts revealed services were provided on 07/25/25, and 08/22/25 and treated for mice and roaches. The documentation for treatments of spiders or ant infestations.

Review of the housekeeping schedule revealed resident room should be cleaned once weekly.

Interview on 08/25/25 at 10:50 A.M with Caregiver #133 revealed that the caregivers were responsible for doing room tidies every day. Caregiver #133 stated housekeeping was responsible for cleaning the resident bathrooms and floors.

Interviews on 08/25/25 from 9:35 A.M. to 1:10 P.M. with Maintenance Director (MD) #114 revealed ecolab pest control maintained a binder including their notes and a log. He was unsure what the log entailed. MD #114 confirmed mice and cockroaches were treated for, but confirmed the facility had no other documentation related to the pest control company being aware of or treating other pests such as ants and spiders. MD #114 reported ants were reported in Resident #51's room due to a significant amount of crumbs. MD #114 confirmed an empty resident room (210) had a large spider around the kitchen cabinet area hanging about a foot from the ground. MD #114 confirmed it was a couple inches in diameter (about the size of an oreo cookie) and stated that's a wolf spider. MD #114 verified several other areas of bugs in this room including on the floor, up on the wall and in the shower area. He reported empty rooms should be cleaned weekly by housekeeping. He also confirmed resident rooms should be given a deep cleaning once weekly.

Interview on 08/25/25 at 3:09 P.M. with Director of Nursing (DON) confirmed resident rooms should each get a weekly deep clean and caregivers should do a touch base cleaning twice daily. The DON verified this would include sweeping up crumbs and taking out trash. The DON verified if an issue was noticed that needed more intensive attention, caregivers can alert housekeeping to address the area of concern. The DON reviewed the housekeeping schedule and confirmed on Monday, the facility had 22 resident rooms scheduled for deep cleans with only one housekeeper scheduled and on Friday, the facility had 21 resident rooms scheduled for a deep clean with only one housekeeper scheduled. She verified the forms showed staff needed more time to clean and verified items were getting missed on the cleaning. She also confirmed if a resident was in their room resting during a deep clean, housekeeping staff should return to complete areas that were missed.

This violation represents noncompliance investigated under Complaint Number OH00167666.

Rule

Ohio Administrative Code - residential care rules

July 15, 2025Licensure survey3 deficiencies▼

R-0338Administered meds - MD ordersOhio citation · correction confirmed 10/08/2025▼

What the surveyor found

Based on observation, staff interview and record review, the facility failed to ensure resident's medications were administered per physician orders. This affected one (#09) out of the three residents reviewed for medication administration. Facility Census was 72.

Findings include:

Review of Resident #09's medical record revealed she was admitted on 06/25/24 with diagnoses that included dementia with behavioral disturbances, anxiety, hyperlipidemia and depression.

Review of Resident #09's Facility Assessment dated 06/24/25, revealed the resident had mild cognitive impairment and she was dependent on staff for administering medications.

Review of the July 2025 active physicians orders for Resident #09, revealed the resident was ordered to receive the following medications: Atorvastatin (lowers cholesterol) 80 milligrams (mg) daily ; calcium carbonate (supplement) 600 mg daily; diltiazem (hypertension) 120 mg daily; donepezil (treatment of dementia) 10 mg daily; doxepin (tricyclic antidepressant) 10 mg daily; famotidine (for gastro esophageal reflux disease[GERD]) 40 mg daily; levothyroxine (thyroid supplement) 112 micrograms (mcg) daily; memantine (treatment of Alzheimer's disease) 10 mg daily; pantoprazole (GERD) 40 mg daily; risperidone (antidepressant) 0.5 mg daily; sertraline (antidepressant) 100 mg daily; triamcinolone (allergies) nasal spray 55 mcg daily. There was no order for self-administering medications.

Observation of medication administration on 07/14/25 at 9:30 A.M., revealed Medication Technician (MT) #111, prepared the following medications for Resident #09; calcium 600 mg; diltaziem 120 mg; donepezil 10 mg; famotidine 40 mg; levothyroxine 112 mcg; memantine 10 mg and sertaline100 mg. MT #111 placed the medications on Resident #09's bedside and left the room without administering them.

Interview on 7/14/25 at 9:35 A.M. with MT #111, confirmed she left the medications in Resident #09's room without administering them. MT #111 stated Resident #09 did not have an order to self-administer medications. When asked how she knew which residents could self-administer, MT #111 stated she just knew the residents and determined if the medications could be left or not. MT #101 also stated she was trained by the nurses to leave the medications at the bedside.

Interview with the Administrator on 7/14/25 at 3:30 P.M., verified Resident #09 was not a resident who could self-administer her medications, and all residents must have a physician's order to do so.

Review of Medication Management Policy, dated 12/19/22, revealed all residents who administer their own medications independently must have authorization, in the form of a written order from the physician, indicating that they are able to administer their own medications.

Rule

Ohio Administrative Code - residential care rules

R-0559Procure, store, prepare, distribute and serve foodsOhio citation · correction confirmed 10/29/2025▼

What the surveyor found

Based on observation and staff interview, the facility failed procure, store, prepare, distribute, and serve all food in a manner that protects it against contamination and spoilage. This had the potential to affect all 72 resident who the facility identified as receiving food from the kitchen. The facility census was 72.

Findings include:

Observation of the kitchen on 7/14/25 at 8:15 A.M. with Cook #139, revealed the dry food storage area had one seven pound can of banana pudding that was dented, and one 6.3 pound can of green beans that was dented.

Interview on 7/14/25 at 8:20 A.M. with Cook #139, verified the cans were dented and should be in the dented can area in the other storage room.

Continued observation of the kitchen on 7/14/25 at 8:30 A.M., revealed the walk-in pantry contained a large bag of vanilla wafers opened and undated; a large bag of spaghetti noodles opened and undated; a pack of 12 hotdog bums with seven remaining in the bag and one bun with a green and white fuzzy substance on it.

Continued observation of the kitchen on 7/14/25 at 8:40 A.M., revealed the walk in refrigerator contained a large pack of hot dogs that had a white substance around them that was opened and undated.

Interview with Dietary Manager (DM) #142 on 07/14/25 at 8:45 A.M., verified the items discovered in the pantry and walk in refrigerator should be dated with an open date.

Rule

Ohio Administrative Code - residential care rules

R-0710Safe and clean environmentOhio citation · correction confirmed 10/08/2025▼

What the surveyor found

Based on observation, staff interview, and review of facility policy, the facility failed to keep a clean-living space. This affected one (#04) of the five residents reviewed for environment. The facility census was 72.

Findings include:

Review of Resident #04's medical record revealed that he was admitted on 09/17/21 with diagnoses that included dementia and Parkinson's.

Review of Resident #04's Facility Assessment dated 05/29/25, revealed the resident required assistance with daily tasks including housework and laundry.

Observation on 07/14/25 at 2:22 P.M. of Resident #04's room, revealed 8-10 large brown spots on the carpet near the bedside, in front of a television stand and in front of a laundry basket that was labeled as dirty clothes. Further observation revealed a pillow in a sitting chair with multiple round yellowish- brown stains. There were also three large hard dried pieces of unidentified food under the air conditioner, and scattered pieces of popcorn kernels on the floor throughout the room and under the bed.

Interview on 07/14/25 at 2:25 P.M. with Resident #04, revealed housekeeping comes about once a week.

Interview on 07/14/25 at 3:11 P.M. with the Administrator, verified the brown spots and food on the carpet. The Administrator stated Resident #04 has his carpet cleaned weekly with the last cleaning being on 07/10/25. The Administrator stated there should be daily cleaning provided by the caregivers.

Review of the facility policy titled Housekeeping dated 02/25/21, revealed it is the policy of the community that housekeeping staff will clean every resident room, common area and office space at least weekly or more often if required.

Rule

Ohio Administrative Code - residential care rules

April 26, 2025Complaint survey1 deficiency▼

R-0338Administered meds - MD ordersOhio citation · correction confirmed 10/08/2025▼

What the surveyor found

Based on medical record review, staff interview, review of the facility Self-Reported Incident (SRI) and policy review, the facility failed to administer a medication as ordered. This affected one (#75) out of three residents reviewed for medication administration. The facility census was 74.

Findings include:

Review of the medical record for Resident #75 revealed an admission date of 01/18/25 with medical diagnoses of multiple myeloma and celiac disease. Review of the medical record revealed a discharge date of 02/01/25.

Review of the medical record for Resident #75 revealed an initial evaluation, dated 01/14/25, which indicated Resident #75 required community assistance with medications.

Review of the medical record for Resident #75 revealed a physician order dated 01/18/25 for Revlimid (anti-cancer medication) 10 milligram (mg) one tablet by mouth daily on day one to fourteen followed by seven days off for 21 day cycle.

Review of the medical record for Resident #75 revealed the January Medication Administration Record (MAR) which revealed documentation to support Resident #75 only received the Revlimid on 01/22/25 and 01/29/25.

Review of the facility SRI, dated 02/03/25, revealed the facility was notified by Resident #75's spouse that Resident #75 did not receive the Revlimid as per physician orders. The facility investigated the allegations and determined Resident #75 had not received the Revlimid as per physician orders.

Interview on 04/26/25 at 10:59 A.M. with Director of Health Services (DHS) #112 confirmed the medical record for Resident #75 did not have documentation to support staff administered the Revlimid as per physician orders. DHS #112 stated the facility's contracted pharmacy entered in Resident #75's medication orders into the electronic health record (EHR) and the facility nurse did not validate Resident #75's physician orders were entered into the system correctly.

Review of the facility policy titled, Medication Administration

Rule

Ohio Administrative Code - residential care rules

November 4, 2024Complaint survey2 deficiencies▼

R-0338Administered meds - MD ordersOhio citation · correction confirmed 10/08/2025▼

What the surveyor found

Based on record review, staff and family interview, and review of the facility policy, the facility failed to ensure medications were administered as physician ordered. This affected two (Residents #59 and #60) of three residents reviewed for medications. The facility census was 58.

Findings include:

1. Review of the medical record for Resident #60 revealed an admission date of 09/12/24 and discharge date 09/16/24. Diagnoses included memory impairment dementia and diabetes mellitus (DM).

Review of the Resident Preadmission Assessment dated 09/03/24 revealed Resident #60 used an outside pharmacy with non-preferred packaging. Resident #60 had an order for facility to assist with medications and was a level one for basic medication pass of two passes.

The physician evaluation dated 09/05/24 (completed prior to admission), revealed Resident #60 had a diagnosis of dementia. The medication list provided by the physician included Aricept (treats dementia) 10 milligrams (mg) to give one tablet at bedtime. Trulicity (treats DM) 4.5 mg inject 0.5 milliliter (ml) weekly subcutaneously. Lexapro (treats depression) 20 mg one tablet daily. Memantine (treats dementia) 10 mg one tablet twice daily. Metformin extended release (treats DM) 500 mg two tablets twice daily. Simvastatin (treats high cholesterol) 20 mg one tablet at bedtime. Vitamin B-12 at 1,000 micrograms (mcg) one tablet at daily. Calcium supplement 600 mg one tablet daily. Resident #60 was assessed to require assistance and supervision by staff for medications.

Review of medication administration record (MAR) dated 09/2024 revealed

- Aricept 10 mg was not administered on 09/13/24.

- Lexapro 20 mg was not administered on 09/13/24.

- Memantine 10 mg was not administered the evening dose 09/12/24 and was not administered two doses on 09/13/24.

- Metformin extended release 500 mg was not administered for one dose on 09/12/24, 09/15/24 and 09/16/24 and two doses 09/13/24 and 09/14/24.

- Simvastatin 20 mg was not written onto the MAR and was not administered on 09/13/24, 09/14/24, and 09/15/24.

- Vitamin B-12 at 1,000 mcg was not administered on 09/13/24.

- Calcium supplement 600 mg was not administered on 09/13/24.

The progress note dated 09/16/24 at 10:42 A.M. revealed Resident #60 was discharged home with spouse and given all belongings and medications at time of departure.

Interview on 11/04/24 at 9:30 A.M. with Resident #60's family stated the resident was admitted on 09/12/24 for respite care and the facility did not administer the medications as physician ordered. The family member stated the facility provided Resident #60's medications to the resident's husband upon discharge and the containers were still full.

Interview 11/04/24 at 12:30 P.M. with Health and Wellness Director (HWD) revealed Resident #60's family was weary about the resident being in the facility. The HWD stated the resident's family brought in her medications and also confirmed Resident's MAR only had entries for part of her stay 09/14/24, 09/15/24 and 09/16/24. The HWD also confirmed issued with missing medications and confirmed the Simvastatin was never transcribed on the MAR and was never administered to Resident #60 during her stay.

2. Review of the medical record for Resident #59 revealed an admission date of 10/01/24 and discharged on 10/15/24. Diagnoses included Alzheimer's dementia, hypertension, anxiety and depression.

Review of the physician assessment dated 10/01/24 revealed Resident #59 had orders for Aspirin (reduces risk of heart attack) 325 mg one tablet daily, calcium carbonate (supplement) 1,000 units one tablet daily and flonase (treats allergies) two sprays daily. Resident #59 was assessed to require supervision with medication administration.

Resident #59's medical record had no records of medication administration and no notations of medication refusals or discussions with the medical team were provided. The facility had no record of separate physician orders or MAR as medications were not provided to Resident #59 during admission.

Interview on 11/04/24 at 12:30 P.M. with Health and Wellness Director (HWD) stated Resident #59 had admitted for a short respite stay. The HWD stated the family reported Resident #59 did not take medications but confirmed this information was not documented in the medical record. The HWD also confirmed Resident #59's physician provided medication orders in the admission assessment and acknowledged they were not written as PRN (as needed). The HWD also confirmed the facility had no evidence of staff calling the physician about Resident #59 and family not wanting her on medications.

Review of the facility policy titled Medication Management

Rule

Ohio Administrative Code - residential care rules

R-0680Maintain building and groundsOhio citation · correction confirmed 07/15/2025▼

What the surveyor found

Based on record review, observation, review of the facility policy, and staff interview, the facility failed to ensure resident rooms and common areas were maintained in a clean and sanitary manner. This affected seven residents (#8, #18, #28, #31, #37, #42, and #43) and had the potential to affect all 58 residents residing in the facility. The facility census was 58.

Findings include:

1. Review of the medical record for Resident #8 revealed an admission date of 10/11/18. Diagnoses included cognitive impairment. Review of the assessment dated 08/06/24 for Resident #8 revealed under the care plan section, room tidying should be done once daily.

Observations on 11/04/24 at 9:58 A.M. and 2:34 P.M. of Resident #8's room revealed trash under the bed and dirty bathroom shower, floor and sink and dust bunnies in the shower.

Observation and interview on 11/04/24 at 2:47 P.M. with Caregiver #55 verified Resident #8's room had trash under the bed and dirty bathroom shower, floor and sink and dust bunnies in the shower.

2. Review of the medical record for Resident #28 revealed an admission date of 07/27/21. Diagnoses included dementia. Review of the assessment dated 07/26/24 for Resident #28 revealed under the care plan section, room tidying should be done once daily.

Review of the medical record for Resident #37 revealed an admission date of 04/01/23. Review of the assessment dated 05/01/24 for Resident #37 revealed under the care plan section, room tidying should be done twice daily.

Observation on 11/04/24 at 9:58 A.M. of Residents #28 and #37's room revealed trash under the bed and over 20 pieces of tissue on both resident's bed, under both resident's bed and in the common area of the room. The bathroom trash was over half full with about five to six balled up tissues and hand towels on the bathroom floor near the trash can.

Observation and interview on 11/04/24 at 2:47 P.M. with Caregiver #55 verified Residents #28 and #37's room had trash under the bed and over 20 pieces of tissue on both resident's bed, under both resident's bed and in the common area of the room. The bathroom trash was over half full with about five to six balled up tissues and hand towels on the bathroom floor near the trash can.

3. Review of the medical record for Resident #31 revealed an admission date of 09/17/24. Diagnoses included dementia. Review of the assessment dated 09/09/24 for Resident #31 revealed under the care plan section. room tidying should be done twice daily.

Review of the medical record for Resident #18 revealed an admission date of 02/16/24. Diagnoses included dementia. Review of the assessment dated 09/02/24 for Resident #18 revealed under the care plan section, room tidying should be done twice daily.

Observations on 11/04/24 at 10:00 A.M. and 2:31 P.M. of Residents #18 and #31's room revealed trash under their beds. In the bathroom, the toilet had dried fecal smears on the toilet seat, inside and outside the bowl. The bathroom trash was over flowing.

Observation and interview on 11/04/24 at 2:47 P.M. with Caregiver #55 of Residents #18 and #31's room revealed trash under the bed. In the bathroom the toilet had dried fecal smears on the toilet seat, inside and outside the bowl, The bathroom trash was over-flowing.

4. Review of the medical record for Resident #42 revealed an admission date of 06/04/24. Diagnoses included dementia. Review of the assessment dated 07/01/24 for Resident #42 revealed under the care plan section, room tidying should be done twice daily.

Review of the medical record for Resident #43 revealed an admission date of 06/04/24. Diagnoses included dementia.

Review of the assessment dated 07/10/24 for Resident #43 revealed under the care plan section, room tidying should be done once daily.

Observations on 11/04/24 at 10:06 A.M. and 2:33 P.M. of Residents #42 and #43's room revealed trash on the floor and bathroom had dust bunnies and large chunks of dirt, the toilet also had a raised toilet seat and a black ring inside the toilet bowl.

Observation and interview on 11/04/24 at 2:47 P.M. with Caregiver #55 of Residents #42 and #43's room revealed trash on the floor and bathroom had dust bunnies and large chunks of dirt, the toilet also had a raised toilet seat and a black ring inside the toilet bowl.

5. Observations on 11/04/24 at 10:19 A.M. and 2:33 P.M. of common area sitting area outside resident rooms revealed trash and crumbs on the floor.

Observation and interview on 11/04/24 at 2:47 P.M. with Caregiver #55 revealed the common area sitting area had trash and crumbs on the floor. She stated housekeeping was to be provided with resident rooms and common areas every day.

Review of the housekeeping scheduled revealed Housekeeper (A) would clean five residents rooms on Sunday, Monday, Tuesday, Wednesday, and Friday and six resident rooms on Thursday. Housekeeper (B) would clean five residents rooms on Sunday, Monday, Tuesday, Wednesday, Thursday, and Friday.

Interview on 11/04/24 at 3:07 P.M. with Maintenance/Housekeeping Supervisor #75 revealed the facility had two housekeeping staff. He revealed resident rooms should have a weekly deep clean done by housekeeping staff, and then a daily touch up cleaning from caregivers.

Interview on 11/04/24 at 3:40 P.M. with Health and Wellness Director and Maintenance/Housekeeping Supervisor (MHS) #75 stated the housekeepers each had a routine schedule. MHS #75 provided the schedule for each housekeeper and they rotated weekends and would have one housekeeper Friday, Saturday, Sunday, and Monday and would have two housekeepers on Tuesday, Wednesday and Thursday. After reviewing the schedule for room cleaning, resident rooms were included one time on either schedule and MHS and Health and Wellness Director confirmed an oversight where resident rooms scheduled for Friday, Saturday, Sunday, and Monday would only have their rooms cleaned every other week.

Review of the resident agreement revealed residents would receive weekly housekeeping services.

Review of facility policy titled Housekeeping and Cleaning Standards dated 10/2022 revealed one housekeeper shall start with the common areas and then assist with resident rooms. The second housekeeper shall complete resident room cleaning with 33% (percent) of all resident rooms to be cleaned daily.

This violation represents non-compliance investigated under Complaint Number OH00158078.

Rule

Ohio Administrative Code - residential care rules

May 16, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

April 11, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

January 16, 2024Licensure survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

November 21, 2023Complaint survey2 deficiencies▼

R-0350Requirements for applications of dressingsOhio citation · correction confirmed 01/16/2024▼

What the surveyor found

Based on medical record review and staff interview, the facility failed to coordinate a residents wound care and the application of a dressing with a home health agency. This affected one (#3) of three residents reviewed for wound care. The facility census was 68.

Findings include:

Review of Resident #3's closed medical record revealed an admission date of 10/19/23. Diagnoses include generalized anxiety disorder, type two diabetes mellitus, congestive heart failure, ad major depressive disorder. Resident #3 was discharged to a local hospital on 10/30/23 and did not return to the facility.

Review of progress notes dated 10/23/23 at 9:39 A.M. revealed that Resident #3 had an un-witnessed fall and sustained a skin tear to her left forearm. Health Services Director (HSD) #9 cleaned Resident #3's left forearm, applied steri-strips (wound closure tape), and covered with a dressing.

Review of physician orders revealed an order dated 10/23/23 for a home health agency to evaluate and treat Resident #3's forearm wound.

Further review of Resident #3's closed medical record revealed no documentation of any dressing change or treatment to Resident #3's left forearm wound form 10/23/23 to discharge 10/30/23.

During an interview with the Administrator and HSD #9 on 11/21/23 at 12:20 P. M. both confirmed that Resident #3 was not evaluated or treated by a home health agency for her forearm wound. Both the Administrator and HSD #9 stated they would expect an interim order for dressing change to have been initiated until the home health agency was able to evaluate.

This violation represents non-compliance investigated under Complaint Number OH00148046.

Rule

Ohio Administrative Code - residential care rules

R-0391Resident incidents and log; identify resident upon requestOhio citation · correction confirmed 01/16/2024▼

What the surveyor found

Based on medical record review, staff interview, and review of facility policy, the facility failed to implement post-fall interventions for a resident. This affected one (#3) of three residents reviewed for falls. The facility census was 68.

Findings include:

Review of progress notes dated 10/21/23 at 1:27 P.M. revealed Resident #3 had an unwitnessed fall. The nightshift caregiver notified the nurse that Resident #3 had fallen around 1:30 A.M. The caregiver responded to Resident #3's call pendant and found her lying on the floor next to her bed. Resident #3 stated to the caregiver that she had rolled out of her bed and hit her head. Health Services Director (HSD) #9 was notified and she instructed the caregiver to monitor Resident #3 through the night and notify of any changes.

Review of progress notes dated 10/21/23 at 1:41 P.M. revealed Resident #3 was sent to the emergency room (ER) at 10:30 A.M. for complaint of headache and left hip pain.

Review of hospital notes dated 10/21/23 revealed Resident #3 was treated post-fall. Resident #3 was diagnosed with closed head injury without concussion, acute thoracic muscle strain, acute cervical muscle strain, contusion of back, contusion of left hip and thigh, and contusion of left knee and lower leg.

During an interview on 11/21/23 at 11:42 A.M. HSD #9 stated the nightshift caregiver called her on 10/21/23 and informed her Resident #3 had fallen. HSD #9 instructed the caregiver to monitor Resident #3 for any changes. HSD #9 confirmed that the nightshift caregiver was not a licensed nurse and that nine-one-one (911) was not called when Resident #3 reported hitting her head during a fall and they should have been called.

Review of the facility's policy titled Fall Management and Post-Fall Investigations dated 05/15/23 revealed if a resident falls and a licensed nurse is not on duty and the resident has hit their head or is suspected to have hit their head, do not move the resident, call emergency services (911). If the resident doesn't wish to be transported to the ER for additional evaluation, allow the resident to refuse transport once the emergency services team has arrived.

This violation represents non-compliance investigated under Complaint Number OH00148046.

Rule

Ohio Administrative Code - residential care rules

September 8, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

March 30, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.