The most recent inspection on file for Brunswick Danbury took place on June 10, 2026. Across the 15 inspections published by the Ohio Department of Health, surveyors cited 11 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 8; 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
Inspections
15 on file · 11 deficienciesJune 10, 2026Complaint survey2 deficiencies▼
R-0338Administered meds - MD orders▼
Based on interview, record review, facilities investigation report, and policy reviews, the facility failed to ensure medication was not administered in error, medical records were documented correctly, and all notifications were completed. This affected one (Resident #57) out of three residents reviewed for medications. Facility census was 89.
Findings include:
Review of the medical record for Resident #57 revealed an admission date of 02/10/23. Diagnoses included but not limited to history of malignant neoplasm of skin, malignant neoplasm of prostate, and osteoarthritis.
Review of the Controlled Drug Receipt dated 12/24/25 revealed Tramadol 50 milligrams (mg) administer by mouth (PO) every 8 hours as needed (PRN). On this document Resident #57 received total of eight doses to include on 05/30/26 two doses, on 05/31/26 two doses, 06/01/26 two doses, on 06/02/26 one dose and on 06/14/26 one dose.
Review of the May 2026 orders revealed an order for Tramadol Hydrochloride (HCI) 50 mg give one tablet PO every eight hours PRN for pain, start date 12/23/25 and Tramadol Hydrochloride HCI 50 mg give one tablet PO twice a day (BID) for pain, start date 05/29/26 and end date 06/02/26.
Review of the June 2026 orders revealed an order for Tramadol Hydrochloride HCI 50 mg administer one tablet PO every eight 8 hours PRN for pain, start date 12/23/25 and Tramadol HCI 50 mg give one tablet by mouth PO BID for pain. Start date 05/29/26 and end date 06/02/26.
Review of the Medication Administration Records (MARS) and Treatment Administration Records (TARS) for May 2026 revealed Resident #57 was administered Tramadol 50 mg 1 tablet BID for pain on May 30, 2026, and May 31, 2026, BID. A total of four doses of Tramadol 50 mg were administered scheduled.
Review of the MARS and TARS for June 2026 revealed Resident #57 was administered Tramadol 50 mg one tablet BID for pain on June 1, 2026, for two doses and on June 02, 2026 one dose was received then the medication was discontinued. A total of four doses of Tramadol 50 mg were administered scheduled.
Review of the Medication Error Investigation document dated 06/02/26 revealed the date error occurred was on 05/30/26 for multiple times that an error occurred. Type of error was listed as other, wrong resident. Description of error: Order for Tramadol was entered in the incorrect resident profile. Resident #57 had a PRN order with medication on the cart. Medication involved in error was Tramadol 50 mg. Notification to power of attorney (POA) and Nurse Practitioner (NP) #292. Medication was discontinued. Progress note and education signed off for all nurses, and corrective action form and signature by Director of Nursing (DON) on 06/05/26. Then added under physician instructions, dated 06/17/26 discussion with Physician ##293 stated it was not an allergy. He has an underlying medical diagnoses for his shortness of breath and lethargy. Physician #293 did a follow up visit with Resident #57. No statements, interviews, or education was provided to surveyor.
Review of the nursing note, authored by DON dated 06/02/26 at 4:42 P.M. revealed the power of attorney (POA) was informed of medication error concerning Tramadol. POA expressed understanding.
Review of the Investigation Report, undated, provided by DON revealed, two pages, no statements, no education, no interviews were included. The Investigation Report stated on June 05, 2026 DON was notified by Resident #57's family about Tramadol during medication pass. DON let family know there was a PRN order for Tramadol. DON spoke with unnamed nurse who reported hospice wrote an order for pain medication. DON looked into chart, no order had been written for Resident #57 for scheduled pain medication. DON called hospice and they did not write an order. DON called NP #292 who reported she did not write an order, and she had written an order for another resident. DON notified POA and Physician that Resident #57 received Tramadol scheduled and did not have an order for it. DON stated nurse put in a new order under the wrong resident. Licensed Practical Nurse (LPN) # 266 was contacted via phone and understood what happened. LPN #266 explained via phone, she was distracted and entered order under wrong resident. Corrective action was written for this nurse.
On 06/10/26, 06/16, 2026, 06/17/2026, 06/17/26 attempts were made to contact LPN #266, the nurse who put the order in for Resident #57 in error. On 06/22/26 at 8:28 A.M. Administrator revealed LPN #266 would call today at 1:00 P.M. On 06/22/26 at 1:00 P.M. interview was attempted and call made to LPN #266, voice message was left and to call back. On 06/22/26 at 1:03 P.M. notified Administrator unable to reach LPN #266, voice message left and Administrator responded LPN #266 works another job and they have been reaching out to her via phone and text with no response.
Interview on 06/11/26 at 8:38 A.M. via phone with Resident #57's POA confirmed Resident #57 was given Tramadol seven doses in error. She confirmed she wasn't notified Resident #57 received Tramadol 50 mg BID in error, not notified of new medication order for Tramadol, hospice wasn't notified of the new medication order, and the medical records were not accurate.
Review of the Corrective Action Form, dated 06/12/26, no time, revealed a final warning for LPN #266 and stated under behavior: On 05/30/26, (LPN #266) entered an order for Tramadol HCL under the wrong resident. This caused the wrong resident to receive seven doses of the wrong medicine before the mistake was caught by the family member. Further stated under Our Expectation: It is our expectation that you are very careful when entering prescriptions into Point Click Care (computer program). Always double check your input to make sure you input it into the correct resident's chart. If this mistake was not found, it could have resulted in harm to the resident who was receiving the medicine that should not have. If this is to happen again, it could be cause for termination. The Correction Action Form did not have employee signature, signature of Manager or Witness signature. The form was blank of any signatures. Attached to the Corrective Action Form was a list of Tramadol HCL 50 mg of the administration history which revealed from 05/30/26 to 06/02/26 seven doses were administered.
Review of the nursing note, authored by DON, dated 06/12/26 at 3:10 P.M. revealed DON spoke with POA and asked if any concerns. Stated they called ombudsman concerning medication and care. POA wanted to add Tramadol to allergy list. MD notified and gave an order to discontinue Tramadol and list as an allergy.
Interview on 06/16/26 at 12:54 P.M. and on 06/17/26 at 7:34 A.M. with DON confirmed Resident #57 received Tramadol 50 mg administered BID for pain. DON confirmed Resident #57 was administered seven doses of Tramadol 50 mg in error. DON reported it was brought to her attention by Resident #57's family during a phone call. DON reported the control drug receipt was signed off incorrectly under the Tramadol 30 mg administer every eight hours PRN for pain for the seven doses of Tramadol administered for the Tramadol 50 mg to administer BID.
Interview on 06/16/26 at 2:25 P.M. with LPN #249 revealed she knows Resident #57 and denied any knowledge of medication given in error to Resident #57.
Review of the nursing note, authored by DON, dated 06/17/26 at 11:12 A.M. revealed she spoke with Physician #293 about Tramadol allergy. Physician instructed DON to take off Tramadol allergy due to the resident did not have an allergic reaction to Tramadol. Physician states that the resident is short of breath due to underlining medical diagnosis.
Interview on 06/17/26 at 1:00 P.M. with LPN #249 with follow-up questions, confirmed DON asked her on 06/02/26, and doesn't remember what time, to see if Resident #57 had an order for Tramadol 50 mg BID. LPN #249 confirmed he did not have an order for Tramadol 50 mg BID. LPN #249 confirmed she discontinued the order per DON on 06/02/26, she already administered the morning dose. LPN #249 confirmed the narcotic sign off sheet for Tramadol 50 mg every 8 hours PRN signed off incorrectly from 05/30/26 to 06/02/26 for a total of seven doses for the Tramadol 50 mg BID. LPN #249 confirmed Resident #57 should not have been scheduled Tramadol 50 mg BID; there was no order. LPN #249 reported he had Tramadol 50 mg order to administer every eight hours PRN.
Interview on 06/17/26 at 1:24 P.M. with Regional Nurse #291 confirmed Resident #57 did not have an order for Tramadol 50 mg BID and was administered from 05/30/26 to 06/02/26 seven doses in error.
Interview on 06/22/26 at 9:22 A.M. with Nurse Practitioner (NP) #292 confirmed she was notified on 06/02/25 doesn't recall time, Resident #57 was administered Tramadol 50 mg BID in error. NP #292 reported she alerted the DON she had written an order for Tramadol 50 mg BID for Resident #49. NP #292 reported Resident #57 received seven doses in error of Tramadol 50 mg BID.
Review of medical records to include nursing notes from 05/29/26 to present revealed no evidence Resident #57 POA was contacted or hospice regarding notification of new medication.
Interview on 06/22/26 at 2:30 P.M. with Hospice Registered Nurse (HRN) #300 confirmed she wasn't notified of the new medication of Tramadol 50 mg administered twice a day for pain for Resident #57. HRN #300 confirmed the facility is supposed to notify hospice with any changes to include new medications.
Review of facility policy, Medication Administration, revised 04/11/22, revealed the policy is to ensure medications are administered to resident consistent with good infection control and standards of practice. Further states medications will be administered to residents as prescribed.
Review of facility policy, Change in Resident Condition, revised on 08/01/2017, revealed the policy is to establish a process to evaluate, monitor, plan, and implement actions to meet resident needs and to notify family and healthcare provider of changes in resident condition.
This violation represents non-compliance investigated under Complaint Number OH00170919 and OH00170566.
R-0391Resident incidents and log; identify resident upon request▼
Based on interviews, record reviews, facilities investigation report, and facility policy reviews, the facility failed to ensure a thorough investigation was completed for wrong medication administered in error. This affected one (Resident #57) out of three residents reviewed for medications. Facility Census was 89.
Findings include:
Review of the medical record for Resident #57 revealed an admission date of 02/10/23. Diagnoses included but not limited to history of malignant neoplasm of skin, malignant neoplasm of prostate, and osteoarthritis.
Review of the Controlled Drug Receipt dated 12/24/25 revealed Tramadol 50 milligrams (mg) administer by mouth (PO) every 8 hours as needed (PRN). On this document Resident #57 received total of eight doses to include on 05/30/26 two doses, on 05/31/26 two doses, 06/01/26 two doses, on 06/02/26 one dose, and on 06/14/26 one dose.
Review of the May 2026 orders revealed an order for Tramadol Hydrochloride (HCI) 50 mg give one tablet PO every eight hours PRN for pain, start date 12/23/25 and Tramadol Hydrochloride HCI 50 mg give one tablet PO twice a day (BID) for pain, start date 05/29/26 and end date 06/02/26.
Review of the June 2026 orders revealed an order for Tramadol Hydrochloride HCI 50 mg administer one tablet PO every eight 8 hours PRN for pain, start date 12/23/25 and Tramadol HCI 50 mg give one tablet by mouth PO BID for pain. Start date 05/29/26 and end date 06/02/26.
Review of the Medication Administration Records (MARS) and Treatment Administration Records (TARS) for May 2026 revealed Resident #57 was administered Tramadol 50 mg 1 tablet BID for pain on May 30, 2026, and May 31, 2026, BID. A total of four doses of Tramadol 50 mg were administered scheduled.
Review of the MARS and TARS for June 2026 revealed Resident #57 was administered Tramadol 50 mg one tablet BID for pain on June 1, 2026, for two doses and on June 02, 2026 one dose was received then the medication was discontinued. A total of four doses of Tramadol 50 mg were administered, scheduled.
Review of the Medication Error Investigation document dated 06/02/26, revealed the date error occurred was on 05/30/26 for multiple times that the error occurred. Type of error was listed as other, wrong resident. Description of error: Order for Tramadol was entered in the incorrect resident profile. Resident #57 had a PRN order with medication on the cart. Medication involved in error Tramadol 50 mg. Notification to POA and Nurse Practitioner (NP) #292. Medication was discontinued. Progress note and education signed off for all nurses, and corrective action form had signature by DON on 06/05/26. Then added under physician instructions, dated 06/17/26 discussion with Physician ##293 stated it was not an allergy. He has an underlying medical diagnosis for his shortness of breath and lethargy. Physician #293 did a follow up visit with Resident #57. No statements, interviews, or education was provided as listed.
Review of the nursing note, authored by Director of Nursing (DON) dated 06/02/26 at 4:42 P.M. revealed the power of attorney (POA) was informed of medication error concerning Tramadol. POA expressed understanding.
Review of the Investigation Report, undated, provided by DON revealed, two pages, no statements, no education, no interviews. The Investigation Report stated on June 05, 2026, DON was notified by Resident #57's family about Tramadol during medication pass. DON let family know there was a PRN order for Tramadol. DON spoke with unnamed nurse who reported hospice wrote an order for pain medication. DON looked into chart, no order had been written for Resident #57 for scheduled pain medication. DON called hospice and they did not write an order. DON called NP #292 who reported she did not write an order, and she had written an order for another resident. DON notified POA and Physician that Resident #57 received Tramadol scheduled in error and did not have an order for it. DON stated nurse put in a new order under the wrong resident. LPN # 266 was contacted via phone and understood what happened. LPN #266 explained via phone, she was distracted and entered order under wrong resident. Corrective action was written for this nurse.
On 06/10/26, 06/16, 2026, 06/17/2026, 06/17/26 attempts were made to contact LPN #266, the nurse who put the order in for Resident #57 in error. On 06/22/26 at 8:28 A.M. Administrator revealed LPN #266 would call today at 1:00 P.M. On 06/22/26 at 1:00 P.M. interview was attempted and call made to LPN #266, voice message was left and to call back. On 06/22/26 at 1:03 P.M. notified Administrator unable to reach LPN #266, voice message left and Administrator responded LPN #266 works another job and they have been reaching out to her via phone and text with no response.
Interview on 06/11/26 at 8:38 A.M. via phone with Resident #57's POA confirmed Resident #57 was given Tramadol seven doses in error. She confirmed she wasn't notified Resident #57 received Tramadol 50 mg BID in error, not notified of new medication order for Tramadol, hospice wasn't notified of the new medication order, and the medical records were not accurate.
Review of the Corrective Action Form, 1 page, dated 06/12/26, no time, revealed a final warning for LPN #266 and stated under behavior: On 05/30/26, you entered an order for Tramadol HCL under the wrong resident. This caused the wrong resident to receive seven doses of the wrong medicine before the mistake was caught by the family member. Further stated under Our Expectation: It is our expectation that you are very careful when entering prescriptions into Point Click Care (computer program). Always double check your input to make sure you input it into the correct resident's chart. If this mistake was not found, it could have resulted in harm to the resident who was receiving the medicine that should not have. If this is to happen again, it could be cause for termination. The Correction Action Form did not have employee signature, signature of Manager or Witness signature. The form was blank of any signatures. Attached to the Corrective Action Form was a list of Tramadol HCL 50 mg of the administration history which revealed from 05/30/26 to 06/02/26 7 doses were administered.
Review of the nursing note, authored by DON, dated 06/12/26 at 3:10 P.M. revealed DON spoke with POA and asked if any concerns. Stated they called ombudsman concerning medication and care. POA wanted to add Tramadol to allergy list. Physician notified and gave an order to discontinue Tramadol and list as an allergy.
Interview on 06/16/26 at 12:54 P.M. and on 06/17/26 at 7:34 A.M. with DON confirmed Resident #57 received Tramadol 50 mg administered BID for pain. DON confirmed Resident #57 was administered seven doses of Tramadol 50 mg in error. DON reported it was brought to her attention by Resident #57's family during a phone call. DON reported the control drug receipt was signed off incorrectly under the Tramadol 30 mg administer every eight hours PRN for pain for the seven doses of Tramadol administered for the Tramadol 50 mg to administer BID.
Interview on 06/16/26 at 2:25 P.M. with LPN #249 revealed she knows Resident #57 and denied any knowledge of medication given in error to Resident #57.
Review of the nursing note, authored by DON, dated 06/17/26 at 11:12 A.M. revealed she spoke with Physician #293 about Tramadol allergy. Physician instructed DON to take off Tramadol allergy due to the resident did not have an allergic reaction to Tramadol. Physician states that the resident is short of breath due to underlining medical diagnosis.
Interview on 06/17/26 at 1:00 P.M. with LPN #249 with follow-up questions, confirmed DON asked her on 06/02/26, and doesn't remember what time, to see if Resident #57 had an order for Tramadol 50 mg BID. LPN #249 confirmed he did not have an order for Tramadol 50 mg BID. LPN #249 confirmed she discontinued the order per DON on 06/02/26, she already administered the morning dose. LPN #249 confirmed the narcotic sign off sheet for Tramadol 50 mg every eight hours PRN signed off incorrectly from 05/30/26 to 06/02/26 for a total of seven doses for the Tramadol 50 mg BID. LPN #249 confirmed Resident #57 should not have been scheduled Tramadol 50 mg BID; there was no order. LPN #249 reported he had Tramadol 50 mg administer every eight hours PRN.
Interview on 06/17/26 at 1:24 P.M. with Regional Nurse #291 confirmed Resident #57 did not have an order for Tramadol 50 mg BID and was administered from 05/30/26 to 06/02/26 seven doses in error.
Interview on 06/22/26 at 9:22 A.M. with Nurse Practitioner (NP) #292 confirmed she was notified on 06/02/25 doesn't recall time, Resident #57 was administered Tramadol 50 mg BID in error. NP #292 reported she alerted the DON she had written an order for Tramadol 50 mg BID for Resident #49. NP #292 reported Resident #57 received seven doses in error of Tramadol 50 mg BID.
Review of medical records to include nursing notes from 05/29/26 to present revealed no evidence Resident #57 POA was contacted or hospice regarding notification of new medication.
Interview on 06/22/26 at 2:30 P.M. with Hospice Registered Nurse (HRN) #300 confirmed she wasn't notified of the new medication of Tramadol 50 mg administered twice a day (BID) for pain for Resident #57. HRN #300 confirmed the facility is supposed to notify hospice with any changes to include new medications.
Review of facility policy, Medication Administration, revised 04/11/22, revealed the policy is to ensure medications are administered to resident consistent with good infection control and standards of practice. Further states medications will be administered to residents as prescribed.
Review of facility policy, Change in Resident Condition, revised on 08/01/2017, revealed the policy is to establish a process to evaluate, monitor, plan, and implement actions to meet resident needs and to notify family and healthcare provider of changes in resident condition.
This violation represents non-compliance investigated under Complaint Number OH00170919.
April 14, 2026Complaint survey3 deficiencies▼
R-0304Content of resident agreement▼
Based on closed record review and interview, the facility failed to ensure the resident's representative was appropriately informed of resident charges for care. This affected one resident (#103) of three residents reviewed for Resident Agreements and billing practices. The facility census was 102.
Findings include:
Review of the closed medical record Resident #103 revealed an admission date of 10/30/23 and a move out date of 03/28/26. Diagnoses include gastrointestinal reflux, type two diabetes, hypercholesterolemia, osteoporosis, urge incontinence, and depression. Resident #103 was discharged to the hospital on 01/18/26 and did not return to the facility.
Review of the Wellness Evaluation dated 10/30/23 revealed Resident was alert and oriented to person place and situation. The resident was noted to be capable of self-administering medications and was independent with ambulation.
Review of the Resident Admission Agreement dated 10/30/23 revealed if the resident was absent [from the facility] for any reason, such as hospitalization, vacation, temporary nursing home or rehabilitation care, the Agreement remained in effect, and the resident would be charged the full rate. The level of care charges would be credited during the Resident's absence after 24 hours until his /her return. There was no explanation to the extent and types of services the facility would provide for the resident and who was responsible for payment. Resident #103 signed the agreement.
Review of the Addendum to Residency Agreement dated 02/19/24 revealed if the Resident was absent [from the facility] for any reason, such as hospitalization, vacation, temporary nursing home or rehabilitation care, the Agreement remained in effect and the resident would be charged the full rate until such time that the resident or representative provides written notice of their intent to terminate the Agreement. There was no explanation to the extent and types of services the facility would provide for the resident and who was responsible for payment. Resident #103 signed the addendum.
Review of the Saint Louis University Mental Status (SLUMS) Assessment, used to evaluate cognition, dated 04/20/24 revealed a score of 28 out 30 which was suggestive of normal cognitive function.
Review of the Wellness Evaluation dated 01/13/26 revealed Resident #103 required staff to administer medication.
Review of the SLUMS Assessment dated 01/16/26 revealed a score of 9 out of 30, which indicated severe cognitive impairment and possible dementia.
Review of the billing statements revealed charges for Assisted Living Care Level One in addition to the facility rent from 01/13/26 through 01/31/26. Resident #103 was also charged for Assisted Living Care Level One from 02/01/26 through 02/28/26 in addition to the monthly facility rent.
Interview on 04/14/26 at 8:30 A.M. with the Director of Nursing (DON) revealed in January 2026, Resident #103 had a decline in health status. Resident #103's Power of Attorney (POA) requested medication assistance for the resident due to the health decline. The POA was advised it would be a Level of Care One and the charge for medication administration and verbally agreed to Resident #103 receiving the additional assistance.
Interview on 04/14/26 at 9:00 A.M. with Business Office Manager (BOM) #282 revealed Resident #103 was independent with care up until the last two months she was at the facility. The BOM explained residents still get charged for the level of care charges, even if the resident leaves to go to the hospital, a rehabilitation center, a leave of absence, or if they died, they are still charged.
Interview on 04/14/25 at 11:14 A.M. with the Administrator stated Resident #103 was her own representative at time the Resident Admission Agreement was signed on 10/30/23. The facility later changed the agreement and added the Addendum to include the fee for level of care to the facility's Residency Agreement. Resident #103 was her own representative and signed the addendum agreement. The resident's POA did not come into play until January 2026 when Resident #103 had a decline in health status and the resident's POA requested additional assistance with medication administration. The Administrator verified the level of care was not updated in the Resident Agreement to explain the type of service the resident would require and the facility did not have evidence of a written notice or explanation of the charges which had been provided to Resident #103's POA for the changes effective January 2026.
This violation represents non-compliance investigated under Master Complaint Number OH00170323.
R-0333Personal care services provided appropriately▼
Based on record review, observation, and interview, the facility failed to ensure staff were trained on urinary catheter care and failed to ensure orders for urinary catheter care were in place. This affected three residents (#60, #88, and #102) of three residents reviewed for urinary management. The facility census was 102.
Findings include:
1. Review of the closed medical record revealed Resident #102 was admitted on 08/12/25. Diagnoses include anemia, anxiety, asthma, chronic kidney disease, hypertension, and pain in the left leg.
Review of the Wellness Evaluation dated 11/20/25 revealed the resident had difficulty verbalizing wants and needs and spoke in a repetitive speech patten. The resident required assistance from one staff for toileting and transfers. The resident had bowel and bladder incontinence. The assessment identified the resident utilized a urinary catheter.
Review of the physician orders for April 2026 revealed no orders for urinary catheter care.
Review of the Treatment Administration Record dated April 2026 revealed no documentation of urinary catheter care.
Observation on 04/09/26 at 9:20 A.M. of urinary catheter care on Resident #102, a female, with Care Associate (CA) #226 and CA #279 revealed Resident #102 was lying a recliner and her urinary drainage bag was lying on the floor. CA #279 stated it was night shift who left the bag on the floor. CA #226 emptied the drainage bag. CA #279 donned gloves and removed Resident #102's brief. CA # 279 wiped Resident #102's labia with a cleaning wipe on each side, CA #279 did not clean or dry the catheter. Resident #102 remained in the recliner during catheter care.
Interview on 04/09/26 at 9:30 A.M. with CA #279 following the observation revealed CA #279 verified she did not clean the catheter. CA #279 stated it was the nurse's responsibility to clean the catheter.
Interview on 04/09/26 at 9:35 A.M. Licensed Practical Nurse (LPN) #280 stated hospice was responsible for cleaning Resident #102's catheter.
Interview on 04/09/26 at 10:00 A.M. with the Director of Nursing (DON) revealed the Care Associates were responsible for emptying the bag and nurses were responsible for performing catheter care. The DON stated she will begin education with staff.
Review of the facility's undated skill instruction procedure titled Catheter care and drainage bag assistance stated for females, gently separate the labia. Provide perineal care per protocol. Cleanse around the catheter insertion site wiping from front to back. Cleanse the catheter washing away from the body and down the catheter for approximately four inches. Rinse well with clean washcloth and water and dry. Catheter care should be completed at least daily and emptying the drainage bag should be completed every eight hours and as needed.
2. Review of the medical record for Resident #60 revealed an admission date of 11/06/26. Diagnosis include anemia, type 2 diabetes, Parkinson's Disease, chronic kidney disease, overactive bladder.
Review of the Wellness Evaluation dated 11/06/25 revealed Resident #60 was alert and oriented to person, place, and situation. Resident #60 had a catheter and had bowel incontinence.
Review of the physicians' orders for April 2026 revealed no urinary catheter orders.
Review of the Treatment Administration Record for April 2026 revealed no documentation of urinary catheter care.
3. Review of the medical record for Resident #88 revealed an admission date of 03/10/26. Diagnoses include type 2 diabetes, acute embolism, benign prostatic hyperplasia, urogenital implants, chronic kidney disease, and obstructive uropathy.
Review of the Wellness Evaluation dated 03/10/26 revealed Resident #88 was alert and oriented to person, place, and situation. Resident #88 had a urinary catheter.
Review of the physicians' orders for April 2026 revealed no urinary catheter orders.
Review of the Treatment Administration Record for April 2026 revealed no documentation of urinary catheter care.
Interview on 04/09/26 at 4:00 P.M. with the Director of Nursing (DON) stated she was new to the position and after reviewing resident charts for urinary catheters she verified there were no orders for urinary catheter care or evidence catheter care was completed for Residents #60, #88, and #102.
This violation represents non-compliance investigated under Complaint Number OH00170211.
R-0390Significant change in resident status▼
Based on record review and interview, the facility failed to timely obtain an ordered urinalysis to timely identify a urinary tract infection (UTI). This affected one resident (#13) of three residents reviewed for urinary tract infection. The facility census was 102.
Findings include:
Review of the medical record for Resident #13 revealed an admission date of 03/11/26. Diagnoses include fracture to right femur, aortic stenosis, dementia, and malnutrition.
Review of the Wellness Evaluation dated 03/13/26 revealed Resident #13 was alert and oriented to person, place, and situation. The evaluation identified bowel and bladder incontinence and noted that the resident required staff assistance to complete the toileting task.
Review of the progress notes dated 03/19/26 revealed Resident #13 had a fall in her room. She was observed sitting upright on the side of her bed. Management was in the room and informed the nurse they found her on the side of her bed kneeled down on her knees and that she had called 911, and that was how they were informed. The resident had no visible injuries. Vital signs were taken. The physician was notified and ordered a urinalysis (diagnostic test that analyzes urine and can diagnose a UTI).
Review of the progress note dated 03/20/26 revealed the nurse made an attempt to obtain a urine specimen. The note explained a urine specimen was collected, however there was white cream floating in the bottom of the hat. The note did not indicate the provider was notified that the specimen was unable to be completed.
Review of the verbal order dated 03/23/26 at 3:40 P.M. revealed a verbal order to collect a urine sample to send for a urinalysis with culture and sensitivity (diagnostic testing that detects and identifies bacteria and yeast in urine to diagnose a urinary tract infection and determine the most effective antibiotic treatment).
Review of the final urinalysis report revealed the sample was collected on 03/24/26 at 12:00 A.M., was received by the laboratory on 03/25/26 at 12:54 P.M., and resulted on 03/25/26 at 6:30 P.M. The bacteria/organism detected was Escherichia coli (E. coli).
Review of the order dated 03/26/26 at 1:26 P.M. for Doxycycline (an oral antibiotic) 100 milligrams (mg) to administer one tablet by mouth two times a day for five days for a urinary tract infection.
Review of the progress note dated 03/26/26 at 4:50 P.M. revealed the Director of Nursing (DON) called the resident's power of attorney (POA) regarding her results from her urinalysis. The DON stated to the daughter that the urinalysis came back positive and the (unnamed) Nurse Practitioner (NP) started the resident on Doxycycline 100 mg twice daily for five days.
Review of the Medication Administration Record for March 2026 revealed the first dose of doxycycline, an antibiotic, was administered on 03/26/26 at 7:00 P.M. This was administered six days after the initial rapid urine test. The antibiotic was completed on 03/31/26 at 7:00 A.M.
Interview on 04/13/26 at 2:26 P.M. with the DON stated the delay in obtaining the urine specimen was due to the resident being incontinent of urine. The DON verified there was a delay in collecting the resident's urine specimen which was not collected until 03/24/26.
This violation represents non-compliance investigated under Complaint Number OH00170211.
March 6, 2026Complaint survey1 deficiency▼
R-0310Written initial and periodic assessments; offer flu and pneumo vaccines▼
Based on record review, staff interview, and facility policy, the facility failed to complete monthly skin evaluations in accordance to physician orders for three (Resident #44, #73, #92) out of four residents reviewed for skin concerns. The facility census was 97.
Findings include:
1. Review of the medical record for Resident #92 revealed an admission date of 05/05/23. Diagnoses included retention of urine unspecified, constipation unspecified, personal history of traumatic brain injury, and iron deficiency anemia unspecified.
Review of the physician orders revealed an order to Complete Monthly Skin Evaluation in Assessments tab for resident every night shift starting on the 8th and ending on the 8th of every month for health maintenance. Order created 11/08/24.
Review of nursing progress notes dated 01/30/26 at 2:12 P.M. revealed the top of the resident's coccyx was reddened. The resident denied pain, and the area was not open. The Certified Nurse Practitioner (CNP) and the resident's daughter were notified.
Review of assessments revealed a monthly skin assessment was completed on 01/09/26. No skin assessments were completed after 01/09/26.
Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #650 on 03/06/26 at 1:27 P.M. confirmed that monthly skin evaluations were not being completed for Resident #92.
2. Review of the medical record for Resident #73 revealed an admission date of 10/31/24. Diagnoses included Parkinson's disease, essential primary hypertension, gastroesophageal reflux disease without esophagitis, and unspecified macular degeneration.
Review of the physician orders revealed an order to Complete Monthly Skin Evaluation in Assessments tab for resident every night shift starting on the 8th and ending on the 8th of every month for health maintenance. Order created 11/08/24.
Review of assessments revealed a monthly skin check was completed on 01/03/26. No skin assessments were completed after 01/03/26.
Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #650 on 03/06/26 at 1:27 P.M. confirmed that monthly skin evaluations were not being completed for Resident #73.
3. Review of the medical record for Resident #44 revealed an admission date of 05/01/21. Diagnoses included diastolic congestive heart failure, presence of coronary angioplasty implant and graft, unspecified dementia moderate with agitation, and anxiety disorder unspecified.
Review of the physician orders revealed the resident had orders to complete a monthly skin evaluation every day shift starting on the 4th and ending on the 4th of each month for health maintenance. Order created 11/04/24.
Review of nursing progress notes dated 02/13/26 at 9:49 A.M. documented red bloody drainage from the right chest wound site. The wound was cleansed with normal saline and dressed per orders.
Review of assessments revealed a weekly skin assessment was completed on 12/29/25. No further skin assessments were completed after this date, and no monthly skin assessments were documented from 12/04/25 to present.
Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #650 on 03/06/26 at 1:27 P.M. confirmed that monthly skin evaluations were not being completed for Resident #44.
This violation represents non-compliance investigated under Complaint Number OH00169741
November 4, 2025Licensure survey1 deficiency▼
R-0559Procure, store, prepare, distribute and serve foods▼
Based on observations and interviews, the facility failed to ensure a clean and sanitary kitchen area. This had the potential to affect all 89 residents who received meals from the kitchen. The facility census was 89. Findings include: Observation on 10/30/25 at 9:30 A.M. of the kitchen revealed Server #500 was in the server area outside of the kitchen. Her hair was pulled back into a ponytail. Server #500 then walked into the kitchen and then walked out into the server area. Server #500 was asked where the hair nets were located and she stated they were located in the middle of the kitchen in a drawer. She verified she was not wearing a hair net and stated she did not have to wear one. Server #500 stated she had to go into the middle of the kitchen to take the residents' orders to the steam tables and counters and then would return to get the plated food. She stated she was instructed she did not need to wear a hair net. Interview on 10/30/25 at 9:40 A.M. with Executive Chef #501 revealed she was unaware the servers had to wear hair nets. She verified there were no hair nets at the door to the kitchen and staff had to walk to the middle of the kitchen to a drawer to get hair nets. Observation on 10/30/25 at 9:45 A.M. of the grill/oven area of the kitchen with Executive Chef #501 revealed the metal backsplash behind had dried grease. On the floor behind the grill/oven area, there was scattered food debris. Under the steam table/serving area, there was dried brown areas where liquids had been spilled, trash and food debris. Executive Chef #501 verified the areas had needed cleaned for a while. Review of the facility policy titled, Sanitation Practices: CulinaryBased on observations and interviews, the facility failed to ensure a clean and sanitary kitchen area. This had the potential to affect all 89 residents who received meals from the kitchen. The facility census was 89.
Findings include:
Observation on 10/30/25 at 9:30 A.M. of the kitchen revealed Server #500 was in the server area outside of the kitchen. Her hair was pulled back into a ponytail. Server #500 then walked into the kitchen and then walked out into the server area. Server #500 was asked where the hair nets were located and she stated they were located in the middle of the kitchen in a drawer. She verified she was not wearing a hair net and stated she did not have to wear one. Server #500 stated she had to go into the middle of the kitchen to take the residents' orders to the steam tables and counters and then would return to get the plated food. She stated she was instructed she did not need to wear a hair net.
Interview on 10/30/25 at 9:40 A.M. with Executive Chef #501 revealed she was unaware the servers had to wear hair nets. She verified there were no hair nets at the door to the kitchen and staff had to walk to the middle of the kitchen to a drawer to get hair nets.
Observation on 10/30/25 at 9:45 A.M. of the grill/oven area of the kitchen with Executive Chef #501 revealed the metal backsplash behind had dried grease. On the floor behind the grill/oven area, there was scattered food debris. Under the steam table/serving area, there was dried brown areas where liquids had been spilled, trash and food debris. Executive Chef #501 verified the areas had needed cleaned for a while.
Review of the facility policy titled, Sanitation Practices: Culinary