The most recent inspection on file for Bickford of Lancaster took place on May 20, 2026. Across the 15 inspections published by the Ohio Department of Health, surveyors cited 22 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 15 inspections listed, the state publishes the surveyor's written findings for 11; for the other 4 it publishes only the date, the type of visit and the number of deficiencies - 4 of which found none.
Facility Details
Inspections
15 on file · 22 deficienciesMay 20, 2026Complaint survey2 deficiencies▼
R-0339Administered meds - given only to and as prescribed▼
Based on staff interviews, resident interviews, record review, and policy review, the facility failed to administer medications as prescribed by physician. This affected three (#81, #143, and #162) of three residents reviewed for medication administration. The facility census was 91.
Findings include:
Review of Resident #81's medical record and facility's incident log dated 05/05/26 confirmed a medication error occurred. Licensed Practical Nurse (LPN) #9 documented Resident #81 received medications intended for another resident. Resident #81 received Eliquis (blood thinner) 5.0 milligrams (mg), Gabapentin (treats nerve pain) 100 mg tablet, Mucinex (treats cold symptoms) 30-600 milliequivalents (meq) extended release, and potassium chloride (vitamin) 20 meq extended release, which were not ordered for Resident #81.
Review of the facility's incident log dated 05/14/26 confirmed a medication error occurred. LPN #58 documented that Resident #162 was inadvertently administered another resident's prescribed medications.
Review of the facility's incident log dated 05/18/26 confirmed medication error occurred affecting Resident #143.. Medication Technician #65 documented Resident #143 was given incorrect medications unintentionally.
Interview on 05/20/26 at 12:30 P.M. with Resident #143 confirmed that she had been administered the wrong medications on one occurrence at the facility.
Interview on 05/20/26 at 5:20 P.M. with Executive Director (ED) confirmed she was aware of the recent medication errors at the facility involving Resident #81, #162, and #143. Two of the three medications that occurred in May 2026 were medication errors in relation to Medication Technician #65. During medication error on 05/05/26 involving Resident #81 and LPN #9, LPN #9 prepared the medication and Medication Technician #65 gave the medication to the wrong resident (Resident #81). LPN #42 and new LPN #58 were responsible for 05/14/26 medication error involving Resident #162. LPN #42 was training LPN #58 at the time. The ED stated that an in-service with the nurses was completed 05/18/26 regarding medication administration in which Medication Technician #65 did attend. After this in service education on medication administration, Medication Technician #65 had another medication error on 05/18/26 where she administered Resident #143 the wrong medications. The ED stated she was in the termination process for Medication Technician #65.
Review of the facility's Medication Administration Policy dated 05/2026 revealed the residents are expected to be identified prior to the administration of medications. Medications should be prepared and administered by the same person.
This violation represents non-compliance investigated under Complaint Number OH00170611.
R-0720Privacy▼
Based on observation, resident and staff interview, and review of resident council meeting minutes, the facility failed to ensure residents received privacy while receiving medications from the licensed personnel. This affected one (#131) of three residents observed for medication administration. The facility census was 91.
Findings include:
Observation of medication administration on 05/20/26 from 11:23 A.M. to 11:33 A.M. revealed nine residents were sitting and standing in line in the hallway waiting to receive medications. At 11:26 A.M., Licensed Practical Nurse (LPN) #22 administered Resident #131 insulin in the hallway, where the other eight residents were.
Interview 05/20/26 at 12:05 P.M. with Resident #86 revealed nurses were slow to administer him medications and residents have to wait in line in the hallway a long time for their medications. Resident #86 stated he does not like doing this three times per day.
Interview 05/20/26 at 5:20 P.M. with Executive Director revealed residents do wait in line for medications in the hallway and extra seating was provided for them there.
Review of the resident council meeting minutes dated 04/03/26 revealed residents were concerned about more couches by the medication room.
This was an incidental finding discovered during the complaint investigation.
April 7, 2026Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼
December 31, 2025Complaint survey1 deficiency▼
R-0712Adequate and appropriate treatment and care▼
Based on interview and record review the facility failed to prevent a resident from exiting the facility unsupervised (elopement). This affected one resident (#65) of three sampled for elopement. The facility census was 81.
Findings include:
Review of Resident #65's medical record revealed a move in date of 12/17/25 and diagnoses of acute anxiety, behavioral disorders associated with dementia, dementia and depression.
Review of Resident #65's previous primary care provider's documentation revealed a note written on 11/03/25 indicating the resident was leaving her home at night per her neighbor who was caring for her.
Review of the facility Resident Assessment dated 12/17/25 at 1:36 P.M. and completed by the Health and Wellness Director (HWD) indicated Resident #65 needed minimal assistance such as occasional help due to forgetfulness and difficulty concentrating due to cognitive impairment. Further review revealed the resident needed minimal assistance such as cueing or reminders if wandering, and requires individualized activities to encourage social engagement due to wandering and elopement risk.
Review of Resident #65's service plan dated 12/17/25 revealed the resident requires cueing or reminders if wandering, individualized activities to encourage social engagement. The care team were to provide redirection when the resident was wandering or attempting to leave the building unassisted in order to keep her safe.
Review of Resident #65's Mini-Mental State Examination (MMSE - a cognitive examination) dated 12/17/25 and completed by the HWD revealed a score of 23/30 indicating mild cognitive impairment.
Review of Resident #65's facility notes revealed a note written by Wellness Nurse #246 on 12/17/25 at 1:59 P.M. stating the resident arrived at the facility and appeared anxious, wanted to go home and was exit seeking. Further review revealed a note written by Wellness Nurse #246 on 12/17/25 at 5:34 P.M. Resident continues with exit seeking behaviors with multiple staff attempts to redirect. Resident did sit down to have dinner and then continues wandering stating she needs to go home.
Further review of the facility notes revealed a note written by Caregiver #221 on 12/18/25 at 5:35 A.M. Resident was upset because she could not find her car, aide called POA (power of attorney) to find out where the car was, POA stated it was at the resident's house. Resident said she wants to go home and will pay someone to take her home or she will hike home. Caregiver #221 made sure management and nurse on duty were aware of Resident #65's statements (as per the facility note documentation).
Review of Resident #65's elopement incident report revealed the resident exited the facility on 12/18/25 around 11:30 P.M. by tearing the window screen and exiting through her window. Her facility watch (used by the facility as a call system and to detect falls) alarm was triggered and staff discovered the resident missing and activated elopement protocol including notifying the police. The police found and returned the resident to the facility. Follow up actions included repair of the window screen, review of elopement prevention measures, and update the care plan to include additional safety interventions. Wellness Nurse #263 entered a note on 12/19/25 at 6:11 A.M. that read Resident was under elopement watch throughout the night by staff.
Review of witness statement dated 12/18/25 written by Caregiver #228 revealed Resident #65 had attempted to exit the memory care unit to the assisted living part of the facility three times between 11:15 P.M. and 11:30 P.M. At 11:30 P.M. Resident #65 was in her room and her fall alert sounded saying outside of the salon, the aide stated she had watched the resident go into her room so she went in there and found the window screen destroyed and the resident missing. She notified the other aides and the nurse and went outside to search for the resident.
Review of witness statement dated 12/18/25 written by Caregiver #230 revealed Resident #65 was found by the police after about 45 minutes.
Review of witness statement dated 12/18/25 written by Wellness Nurse #263 revealed she was notified of the resident being missing and staff checked the building and the outside of the building and she notified management, the police and the resident's family. She was returned to the facility by the police and the Health and Wellness Director (HWD) assessed her and found her to be ok.
Review of Resident #65's psychiatric evaluation dated 12/19/25 revealed the resident had a brief interview for mental status score of three indicating the resident was severely cognitively impaired. Zoloft 50 milligrams daily and Namenda 5 milligrams twice daily were added to the resident's medication list and it was recommended the resident be encouraged to participate in groups and activities.
Review of Resident #65's special care needs in her care routines plan, updated on 12/30/25, indicated the facility was installing window alarms and the resident was seeing the facility psychiatry provider.
In an interview on 12/29/25 at 1:53 P.M. Resident #65's niece revealed the resident had significant memory loss and could not recall new information for more than a few minutes at a time. The niece stated the resident did not dress appropriately for the weather, she had walked to a neighbor's wearing flip flops and a wind breaker in 20 degree weather recently. She stated that she had stayed with the resident recently and the resident was up all night wandering the house. She stated the facility was aware of the resident's wandering.
In an interview on 12/29/25 at 2:30 P.M. with Resident #65's former neighbor revealed the resident had, in the past couple of months, gone to another neighbor's house at 3:00 A.M. and walked into the the bedroom and asked that neighbor why they were in bed. The former neighbor stated this had occurred at least three times to her knowledge. The former neighbor further stated that she believed the resident was up wandering her own home at night most nights.
In an interview on 12/29/25 at 3:02 P.M. the HWD stated that she assessed the resident on 12/18/25 when she was returned to the facility and found her to be confused but uninjured. The resident was found by the police across the street in a residential area. The HWD stated that she assisted the resident to change her clothes upon her return to the facility as it had been raining outside. The HWD stated the resident was wearing off white capris style pants, a sweater and a hat and she assisted her into changing into fleece pajamas. Resident #65's temperature upon her return to the facility was 98.5 degrees Fahrenheit.
In an interview on 12/29/25 at 3:50 PM the HWD stated the widow screen was replaced and an alarm was ordered for the window but had not been delivered.
In an interview on 12/30/25 at 11:30 A.M. the HWD stated the root cause of the elopement was the resident did not want to be at the facility. The HWD stated the staff is keeping her engaged in activities during the day and checking on her four times during the night.
In an interview on 12/30/25 at 12:45 P.M. the Executive Director stated they were aware Resident #65 had dementia and that she wandered, that was why they placed her on the secure memory care unit. The facility felt that the memory care unit was very secure and they did not anticipate her going out of a window. The ED stated that she ordered five window alarms that would sound loudly when a window was opened. One of the alarms is for Resident #65 and the rest are for use with any future residents who exit seek. The alarms are to arrive on Friday (01/02/26).
An interview was attempted with Resident #65 on 12/24/25 at 10:30 A.M. and again on 12/29/25 at 3:45 P.M. without success. The resident was unable to answer screening questions.
This violation represents non-compliance investigated under Complaint Number #169220.
This violation is a recite to the complaint survey completed 10/15/25.
October 15, 2025Complaint survey2 deficiencies▼
R-0661Maintain clean environment; housekeeping, garbage, rodents▼
Based on observation, interview, and review of housekeeping policies, the facility failed to ensure furniture was maintained appropriately. The facility also failed to ensure chemicals were secured in a locked cabinet on a memory care unit. This had the potential to affect all residents residing in the facility. The facility census was 90.
Findings include:
1. Observation on 10/15/25 at 7:51 A.M. revealed in the main restroom off the main dining room had feces on the door handle to the wheelchair accessible toilet. There were also feces on the toilet seat of the toilet in the first stall and feces in both toilet bowls of the other stalls. Housekeeper #58 verified the observation at the time.
Interview on 10/15/25 at 7:53 A.M. with Housekeeper #58 who stated she is the only housekeeper for the facility, and she works Monday through Friday 7:30 A.M. until 4:00 P.M. Housekeeper #58 stated the main restroom off the main dining room is like that most of the time and confirmed the residents do use this restroom. Housekeeper #58 stated she cleans the main common areas daily and the caregivers are to clean in between when she isn't in the facility.
2. Observation of the memory care unit on 10/15/25 at 8:56 A.M. revealed a grey love seat facing the dining area with multiple large, brown urine stains which covered the grey cushion in the back of the love seat, down the front of the love seat and on top of the cushion where residents sit. There were also four blue chairs with a leaf-like pattern which had brown stains in variable sizes. One of the blue chairs with a leaf-like pattern had a brown stain in the middle of the seat cushion, the size of a playing card. The other three blue chairs with a leaf-like pattern had several brown stains the size of dimes and quarters in each of the chairs. In addition, there were two multi-colored chairs of blue, brown, and beige color on the memory care unit which contained multiple dime and quarter size brown stains and brown urine ring stains on the bottom seat cushions in each of them. Licensed Practical Nurse (LPN) #29 confirmed the multiple brown stains, brown urine ring stains in each of the six chairs and the two grey love seats at the time of the observation. LPN #29 stated the furniture only gets spot cleaned as needed.
Interview on 10/15/25 at 9:13 A.M. with Caregiver #43 confirmed the odor on the grey love seat with the large, brown urine rings was urine odor. Additionally, Caregiver #43 stated the furniture was only spot cleaned when a resident soils it and that there is no deep cleaning of the furniture on the memory care unit.
3. Observation on 10/15/25 at 9:18 A.M. of the kitchen cabinets on the memory care unit revealed one bottle of odor eliminator, two bottles of bathroom cleanser, three containers of dishwasher liquid for the dishwashers, one bottle of bathroom cleanser, all bottles were opened and being used and located in unlocked cabinets. Health and Wellness Coordinator #28 confirmed the opened containers in unlocked cabinets at the time of the observation.
4. Observation on 10/15/25 at 9:18 A.M. of the cabinets under the serving counter on the memory care unit revealed dark black and brown spots under the sink area, the bottom falling in on the bottom of the inside cabinet and looked wet and mostly black and brown. Both cabinets were unlocked. Health and Wellness Coordinator confirmed at the time of the observation.
5. Observation on 10/16/25 at 1:47 P.M. in the assisted living common area in front of the receptionist desk revealed two grey love seats which had large brown urine rings on the back of the love seats, the front going down the love seats, and on the seat cushions of the love seats. LPN # #34 confirmed the brown urine ring stains on both grey love seats at the time of the observations.
Interview on 10/15/25 at 7:59 with Caregiver #42 who stated that housekeeping does scheduled cleaning, but if the caregivers see something which needs to be cleaned even in the common areas, they are to clean it.
Interview on 10/16/25 at 11:42 A.M. with LPN #41 who stated if she sees furniture which needs cleaned, she will tell the caregivers to clean the furniture with the green machine or to take the cushions off and clean them.
Review of the facility Resident Handbook, undated, stated under housekeeping and laundry revealed the facility would maintain a clean, aesthetic and pleasant building for the physical and well-being of all our residents, staff, and visitors.
Review of the facility Admission Agreement, undated, under Housekeeping, Laundry, and Maintenance Service stated housekeeping services shall include cleaning of community space and availability of cleaning of apartment, including bathroom, kitchen area, and other living space.
This violation represents non-compliance investigated under Complaint Number OH00168495.
R-0712Adequate and appropriate treatment and care▼
Based on observations, record review, staff interviews, and facility policy, the facility failed to respond to an elopement and failed to investigate an elopement. This affected one (Resident #20) of three reviewed for elopement. This facility census was 90.
Findings include:
Review of the medical record for Resident #20 revealed an admission date of 09/15/25 with medical diagnoses of osteoarthritis, paresthesia of both feet, Schatzki's ring, spinal stenosis, vitamin B-complex deficiency, cataract, and skin cancer.
Review of the mini mental state examination (MMSE) dated 09/18/25 revealed Resident #20 scored 18 out of 30 which indicated mild cognitive impairment.
Review of the Resident Care Summary pulled 10/16/25 indicated Resident #20 is an elopement risk.
Review of the progress note dated 10/03/25 at 11:21 P.M. created by the Division Director of Operations (DDO) stated Resident #20's daughter contacted DDO to report that the resident was not in the facility and had shown up at her sons' residence. Upon receiving this information, DDO immediately went to the branch and spoke with the Executive Director (ED) and floor staff. The ED promptly utilized bus to go bring the resident back to the branch. The POA was notified of the actions taken to ensure the residents safe return and continued well-being. An investigation is being completed.
Interview on 10/15/25 at 11:22 A.M. and 12:49 P.M. with Resident #20's POA stated Resident #20 showed up at the resident's home address, which is where POA's son is staying. POA stated she called the DDO on 10/03/25 at 5:00 P.M. because she had made a complaint to the facility corporate office on 09/29/25 and had spoken to the DDO on 09/29/25 about the lack of communication, as she had been trying to reach the ED for two weeks. The POA stated that on 09/29/25 she had told the DDO that Resident #20 would try to leave the facility and the DDO stated that there was no way the resident could leave the facility without someone knowing. The POA stated she received a call from her son on 10/03/25 that Resident #20 had showed up at the house, and he didn't know how she had gotten there. The POA called the DDO because she had her number from their discussion on 09/29/25. The POA reported she asked the DDO if she knew where Resident #20 was and the DDO stated that Resident #20 was at the facility. The POA then told the DDO that Resident #20 was at the home address with Resident #20's grandson and they don't know how Resident #20 got to the house. POA stated the DDO said she would have someone go to pick up the resident at the home address and return her to the facility. The POA called the local police to Resident #20's home address. The POA stated there was one and a half hours unaccounted for between the last time Resident #20 was seen in the facility until she showed up at the home address. The POA reported there was no real follow up on 10/04/25 and that she hasn't heard anything else from leadership regarding the incident. The POA reported Resident #20 does not take off her alarm bracelet unless she is scratching her wrist and then puts it back on immediately.
Interview on 10/15/25 at 11:22 A.M. and 12:49 P.M. with Resident #20 stated she walked out of the facility and up to the road to walk home. Resident #20 stated she is not familiar with the area, but as she was walking a man stopped and asked her where she was going. Resident #20 stated she told the man she was going home and that the man dropped her at the end of her home address driveway. Resident #20 stated she was walking a long way before the man stopped. She reported it was hot that day. Resident #20 stated that the ED picked her up at home and took her to the ED's home and then brought her back to the facility on 10/04/25.
Interview on 10/15/25 at 1:17 P.M. with Occupational Therapy Assistant (OTA) #70 reported Resident #20 has cognitive deficits, memory and orientation are both inconsistent. OTA #70 stated Resident #20 does pretty well functionally but does need assistance with Activities of Daily living (ADLs) for hygiene, reminders to change her clothes, and reminders to complete a toilet with proper hygiene. OTA #70 stated prior to 10/03/25, Resident #20 was always asking for a phone to call a taxi and was exit seeking. OTA #70 stated she wasn't surprised that Resident #20 had left the facility but was surprised that Resident #20 made it all the way to Canal Winchester.
Interview on 10/15/25 at 3:11 P.M. with Resident #83 who had a key fob for the front door. Resident #83 reported he usually sits by the front door. Resident #83 reported he doesn't know all the names of the residents in the facility, but he recognizes some. Resident #83 also stated if a resident doesn't have a key fob, then he would let them out the front door with his key fob. Resident #83 reported if there was a new resident and he didn't know them, then he would probably let them out the front door with his key fob.
Interview on 10/15/25 at 2:08 P.M. with Caregiver #25 stated she was working on 10/03/25 during the evening shift when Resident #20 left the facility. Caregiver #25 reports there are alarms on the doors, but if you push on them, they will open after fifteen seconds. Additionally, she stated the alarm goes off really loud in the facility. Caregiver #25 stated you can hear the alarm anywhere in the building and on the work phone. Caregiver #25 reported the alert on the work phone when the door alarms says geo-fence with the resident's name who is near the door or out of the door. The alert on the work phone says temp not connected when the battery needs changed or the resident is outside of the area of the alarm. Caregiver #25 stated on 10/03/25 there was an alert which came to her work phone, but she didn't look at it until 5:00 P.M. Caregiver #25 stated the work phone does buzz or makes noise to let you know there is an alert. Caregiver #25 stated she went to Resident #20's room around 5:00 P.M. on 10/03/25 and the room door was locked. She reported she had to find another caregiver to get a key to go into Resident #20's room and when the door was opened, they discovered Resident #20 was gone. Caregiver #25 stated she didn't hear any door alarms beeping on 10/03/25. Caregiver #25 reported she has known Resident #20 to not be allowed outside unsupervised since Resident #20 was admitted to the facility.
Interview on 10/15/25 at 2:40 P.M. with Licensed Practical Nurse (LPN) #34 stated she was working at the facility on 10/03/25. LPN #34 reported she observed Resident #20 in the medication room about 3:00 P.M. LPN #34 reported she did not know Resident #20 was missing until the DDO came into the facility at about 5:40 P.M. on 10/03/25 and asked LPN #34 if she knew where Resident #20 was at. LPN #34 told DDO that she had last seen Resident #20 around 3:00 P.M. LPN #34 stated she did not hear the door alarms on 10/03/25 and she did not observe Resident #20's alarm bracelet in Resident #20's room. LPN #34 reported Resident #20 is confused at times and doesn't like being at the facility. LPN #34 stated she isn't sure how long Resident #20 was out of the facility.
Interview on 10/15/25 at 4:09 P.M. with Resident #20's Grandson, who had lived with Resident #20 for 22 years before Resident #20 went to live in the facility, revealed Grandson reported he saw Resident #20 walking up the driveway to the home on 10/03/25 at about 5:00 P.M. Resident #20 was wearing a sweater, sweatpants, and shoes and had her purse with her. Grandson stated Resident #20 wanted a television (t.v.) dinner and ice cream which she ate at the kitchen table. Grandson reported Resident #20 was confused and kept talking about going to work. Grandson reported Resident #20 does have a cell phone and was wearing her alarm bracelet when she arrived at the home address. Grandson stated Resident #20 had multiple falls over the summer, was confused and hallucinating, and walking out of the house confused which is part of the reason Resident #20 was in the hospital and then transferred to the facility. Grandson reported Resident #20 was at the home address for about one and a half hours before the police and facility staff arrived to take Resident #20 back to the facility.
Interview on 10/16/25 at 1:57 P.M. with Caregiver #14 who reported the alert on the work phone will say geo-fencing with the resident's name if the resident is near the door or has left through the door and once the resident gets to the main road, then the alert would say tempo not connected with the resident's name. It does this when a resident leaves for an appointment or if the resident leaves with their family. Then you go into the alert on the work phone and there are options which you can choose, like family or appointment or if it's a mistake and the resident is still here, then you can press test. Caregiver #14 also stated most residents who can be outside unsupervised have a key fob and the ones who don't have a key fob to get outside are the ones who can't be outside unsupervised. You don't really know which residents are not allowed unsupervised. Caregiver #14 stated that once you work here for a while, then you learn who the residents are and who can't be outside unsupervised.
Interview on 10/16/25 at 2:21 P.M. Caregiver #3 stated she has heard the front door alarm and it's really loud and obnoxious, the front desk phone starts ringing and calls all the work phones. Caregiver #3 reports she wasn't working on 10/03/25. Caregiver #3 stated Resident #20 is confused. Everyday Resident #20 asks for her room number and talks to Caregiver #3 about random things. Caregiver #3 stated Resident #20 sits near the front door all the time and always has her purse with her. Caregiver #3 reported that she doesn't know of any residents who are allowed to be outside unsupervised.
Interview on 10/16/25 at 2:36 P.M. with Health and Wellness Coordinator (HWC) #28 stated she was off work on 10/03/25 but received a call at 7:40 P.M. from DDO who asked her to come to the facility and complete a skin assessment on Resident #20 which she did and it was noted in the progress notes. HWC stated she was not aware of anything being stated that Resident #20 could not be allowed outside unsupervised and since her MMSE was 27 and she lives in the Assisted Living unit, then she is allowed to go outside unsupervised. HWC #28 reported she doesn't know if Resident #20 has a key fob. HWC #28 stated she has not seen Resident #20 going to the exit doors and wasn't alerted by family of Resident #20's exit seeking behaviors. HWC #28 reported that alarm bracelets are standard issue to all the residents when they come to live at the facility. HWC #28 reported there was an investigation completed on the evening of 10/03/25 and the staff on duty that night were re-educated. HWC #28 stated there is no documentation that the staff were re-educated on 10/03/25 and there is no documented investigation. Additionally, HWC #28 stated she can't find the maintenance for the door alarm system.
Interview on 10/16/25 at 3:50 P.M. with the Health and Wellness Director (HWD) stated she was off work on 10/03/25 and was not aware that Resident #20 had left the facility until 10/04/25. HWC reported the on alert by the progress notes means we are to continue to watch the residents as they could be an escape artist. We should be on alert and watch for them. HWC stated that Resident #20 and POA have been very vocal about Resident #20 wanting to leave the facility, but that she hasn't seen Resident #20 by the exit doors. HWC reported that POA has two key fobs and she isn't sure if Resident #20 has one. HWC stated that Resident #20 is allowed to go outside unsupervised as she lives in the Assisted Living unit. HWC verified the MMSE score of the MMSE she gave to Resident #20 on 09/29/25 as 18/30 to indicate mild cognitive impairment. HWC verified there was no investigation documentation related to the incident on 10/03/25.
Interview on 10/16/25 at 4:15 P.M. with DDO confirmed she received a call from Resident #20's POA at 5:04 P.M. on 10/03/25 alerting her to the fact that Resident #20 was no longer at the facility and was at the home address. The DDO reported she tried to reach someone at the facility but was unable to reach anyone, so she drove to the facility and spoke to them. Then the DDO called the ED (who is no longer working for the facility since 10/04/25) who took the facility bus and went to pick up Resident #20 at the home address. The DDO reported she waited at the facility for the ED and Resident #20 to return to the facility. The DDO also called HWC and asked her to complete a skin assessment on Resident #20 when she returned to the facility. The DDO stated she gave instructions to the ED and HWC to investigate the incident on 10/03/25. The DDO confirmed there is no documented investigation or re-education of the staff regarding the incident which occurred on 10/03/25. The DDO reported that the ED must have taken it with her when she quit. The DDO verified that Resident #20's alarm bracelet was not connected to the facility's system at 3:47 P.M. or 3:57 P.M. on 10/03/25 and did not re-connect until Resident #20 was returned to the facility.
Review of the facility Door Inspection Sheet dated 09/26/25, 10/03/25, and 10/10/25 revealed the front door alarm was working and no repairs needed.
Review of the facility Life Safety policy dated 12/2024 stated resident incidents or accidents are to be reported and documented immediately after they occur. Additionally, the facility Life Safety policy stated incidents or accidents can include but are not limited to f) resident elopements. The ED and or HWD/HWC shall a) investigate incidents or accidents involving resident b) document investigation and corrective action regarding the incident or accident c) implement corrective action as appropriate e) incidents that negatively affect or that threaten the life, health, safety, or welfare of any resident will be reported per State Licensing Agency.
Review of the personnel files for all staff working on 10/03/25 revealed no education for elopement training before or after 10/03/25.
Review of Google map revealed the distance from the facility to Resident #20's home address is between 19 miles to 23.2 miles depending on the route taken and approximately 26 minutes to 34 minutes to arrive by driving.
This violation was an incidental finding found during the course of the complaint investigation.
September 29, 2025Complaint survey2 deficiencies▼
R-0333Personal care services provided appropriately▼
Based on medical record review, staff interviews, and facility policy review, the facility failed to provide adequate supervision and assistance during toileting for a resident assessed at the highest fall risk. This resulted in Actual Harm when Resident #97 was left unattended in the bathroom, fell off the toilet, and sustained a cervical (neck) fracture and forehead avulsion (body structure is torn off by either trauma or surgery). This affected one (Resident #97) of seven residents reviewed for accidents. The facility census was 94.
Findings include:
Review of Resident #97's medical record revealed an admission date of 10/18/21.
Resident #97's fall risk assessment dated 07/09/25 identified the resident as a Level III fall risk, the highest category, due to a history of falls with injury, unsteady gait, transfer/ambulation problems, and cognitive decline.
The service plan dated 07/09/25 directed staff to provide full assistance with all bathroom activities and hygiene, including scheduled and unscheduled escorts and incontinence care. The plan also required hands-on assistance with transfers and instructed staff to always watch when Resident #97 was up and walking. Resident #97 required frequent help due to disorientation, memory loss, and difficulty completing tasks. Resident #97 had poor safety awareness and had sun downing which started around 3:00 P.M. daily. The special care needs plan for frequent and ongoing assistance with addressing special care needs. Safety checks were three times per shift.
Review of the progress notes revealed Resident #97 fell multiple times and sustained injuries. Resident #97's falls included the following seven dates: 10/02/24, 12/14/24, 01/27/25, 03/21/25, 04/11/25, 06/21/25, and 08/31/25. Resident #97 fell in the bathroom on five of the falls (10/02/24, 12/14/24, 01/27/25, 06/21/25, and 08/31/25).
On 10/02/24 at 12:50 A.M., Resident #97 was found on the bathroom floor after attempting to use the toilet, sustaining a skin tear to the right elbow. The fall intervention was added safety checks to service plan to take to bathroom more often and make sure Resident #97 was safe.
On 12/14/24 at 8:00 P.M., Resident #97 was found in the bathroom on her back with head under the sink, reporting confusion and had knee and elbow pain. The fall intervention was increasing Resident #97's involvement in activities.
On 01/27/25 at 7:00 A.M., Resident #97 was found on the bathroom floor near the sink after toileting, complaining of midback pain with redness noted to her back. The fall intervention was 'increased' (undefined) safety checks.
On 03/21/25 at 4:06 P.M., Resident #97 fell while walking without her rollator, she fell and sustained a left hip fracture and required hospitalization. Fall interventions were to remind Resident #97 to always use her walker and make sure it is within her reach.
On 04/11/25 at 8:46 P.M., Resident #97 fell while in her room sustaining a skin tear. The fall intervention was frequent safety checks four times per shift; However, the fall intervention was not listed in Resident #97's service plan.
On 6/21/25, Resident #97 was found in the bathroom next to sink. Resident #97 took herself to the bathroom and fell backwards and cut her elbow and arm. All staff were re-educated to assist residents with toileting on 08/11/25. During an interview with Health Wellness Coordinator (HWC) on 09/29/25 at 12:55 P.M., she started in the HWC position in June and was not aware of implementing new fall interventions after a resident's fall and this was the reason for the delay in intervention for Resident #97's fall on 06/21/25.
On 08/31/25 at 7:40 A.M., a resident care assistant (RCA) took Resident #97 to the bathroom and sat Resident #97 on the toilet and stepped outside the room briefly and found Resident #97 on the floor with a forehead injury. Resident #97 complained of feeling dizzy, and her head and the back of her neck hurt. Resident #97 was removed from the floor and placed back into her chair and her forehead injury opened and the skin and tissue were pushed back and was bleeding. The nurse applied a towel on her head with pressure to control bleeding. Emergency 911 was called, and Resident #97 was taken to the emergency room (ER). At the hospital, Resident #97 was diagnosed with a C2 neck fracture and forehead avulsion. The fall intervention was Resident #97 was not to be left alone in the bathroom.
Review of RCA #500's statement revealed on 08/31/25, RCA #116 assisted Resident #97 with morning care. Resident #97 was assisted to the bathroom and Resident #97 requested some privacy. RCA #116 stepped outside the bathroom door when RCA #116 heard a loud thud. RCA #116 peaked into the bathroom and saw Resident #97 on the floor.
Review of Licensed Practical Nurse (LPN) #600's written statement revealed when LPN #600 entered Resident #97's bathroom, the resident was sitting on her floor and wanted to get up. RCA #116 and LPN #600 assisted Resident #97 to her wheelchair and saw the resident had an injury to her forehead that was bleeding and applied a towel to her head to stop the bleeding. Resident #97 complained that her neck hurt.
Review of the Disciplinary/Counseling Report dated 09/04/25 revealed RCA #116 received her first warning for violating the company's policy. On 08/31/25 at 7:40 A.M., RCA #116 left Resident #97 in the bathroom, sitting on the toilet and stepped outside the bathroom door at resident's request. This violated the resident's service plan.
In an interview on 09/15/25 at 5:20 P.M., the Director of Nursing stated the aide should have requested assistance rather than leaving the resident alone and confirmed the facility had no formal policy on how long residents may be left unattended in the bathroom.
In an interview on 09/29/25 at 1:15 P.M., the Administrator verified RCA #116 had received a written warning for failure to follow Resident #97's service plan.
Review of the facility's Resident Supervision and Safety policy revealed it required staff to follow each resident's individual service plan to ensure safe provision of care.
This violation represents non-compliance investigated under Complaint Number OH00168165.
R-0711Free from abuse▼
Based on observation, record review, staff interviews, and review of facility policy, the facility failed to ensure Residents #84 and #85 were free from abuse. This affected five (Residents #2, #79, #80, #84, and #85) of seven residents reviewed for abuse. The facility census was 94.
Findings include:
1. Review of Resident #80's medical record revealed an admission date of 02/05/24. Diagnoses included dementia with agitation and mood disorder.
Resident #80's service plan dated 01/09/25 directed psycho-social engagement activities in the afternoon and evening and safety checks three times per shift due to agitation and exit-seeking.
Review of the progress note dated 09/14/25 at approximately 2:00 P.M., a resident care assistant (RCA) reported hearing a resident yelling Leave me alone. Upon turning to assess the situation, the RCA witnessed Resident #80 physically assaulting another resident (#84) by punching them in the face. A police report was filed.
Review of Resident #84's medical record revealed an admission date of 12/03/22. Diagnoses included altered mental status and bipolar disorder.
During an interview on 09/14/25 at 9:38 A.M., Licensed Practical Nurse (LPN) #86 confirmed Resident #80 struck Resident #84 in the face in the memory care unit. Resident #84 did not exhibit visible injury. Resident #80 was transported to the hospital for a psychological evaluation and returned later the same day.
During an interview on 04/14/25 at 4:02 P.M., RCA #12 confirmed she observed Resident #80 physically punch Resident #84 in the face.
2. Review of Resident #79's medical record revealed an admission date of 09/05/24. Diagnoses included dementia, insomnia, and bipolar disorder.
Review of the progress note dated 09/27/25 at 2:30 P.M. revealed Resident #79 was yelling at another resident (#2) when another resident (#85) went to intervene, he started to choke Resident #85.
Review of the written statement by Resident Care Associate (RCA) #135 dated 09/27/25 revealed Resident #79 yelled at another resident (#2), then placed both hands around Resident #85's neck. Resident #85 was noted with redness to the neck.
During an interview on 09/29/25 at 8:43 A.M., RCA #139 stated she assisted in the unit while police interviewed the RCA (#135) who witnessed the event. Facility documentation confirmed law enforcement responded, and staff were interviewed on-site.
During observations on 09/29/25 at 8:45 A.M., Resident #85 did not have any bruising or redness around her neck.
During an interview on 09/29/25 at 10:57 A.M., the Director of Nursing (DON) confirmed Resident #79 strangled Resident #85 using his hands. The DON stated she was working on the unit during this time but did not witness the incident. RCA #135 was in the dining room cleaning up tables. Resident #79 started to yell at Resident #2 and Resident #85 and RCA #135 came to intervene and Resident #79 started to strangle Resident #85's neck. RCA #135 immediately got Resident #79's hands off Resident #85. Resident #85 cried for a few seconds then was calm. The DON took Resident #79 outside and administered as needed Xanax (anti-anxiety medication) to Resident #79. Resident #79 was unable to recall the incident and remained calm during the rest of the day. Resident #79 has been taking his medications routinely for the past three months. Resident #79 was seen by psych in June and changed his medications and he has been stable since then.
Review of the facility's Abuse and Neglect policy last revised 02/2025 revealed the residents were to be free from abuse.
This violation represents non-compliance investigated under Complaint Number OH00168165.
This violation is an example of continued non-compliance from the survey dated 08/13/25.