Widows Home of Dayton

Inspectors wroteBased on record review, observations, interview, and facility policy review, the facility failed to provide a sanitary and home like environment in resident rooms. This affected four Residents ( #22, #23, #26 and #27) of seven residents reviewed for sanitary homelike and environment. The facility total census was 64. Findings Include: 1. Record review of Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #26 include joint replacement of right femur, osteoporosis, dementia, severe malnutrition, and dysphagia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Observation on 06/14/26 at 8:10 A.M. revealed Resident #26's bed had a broken headboard. [...]

Inspectors wroteBased on observations, interview, and facility policy review, the facility failed to provide a sanitary and home-like environment in common area. This affected 8 residents (Resident #21,#22, #23, #24, #15, #26,#27, and #28) residing on the 200 unit . The facility total census was 64. Findings Include:Observation on 06/17/26 from 8:10 A.M. through 8:22 A.M. of unit 200 hallway and room entrances of Resident #21, #22, #23, #24,#15, #26,#27, and #28 revealed a gray and blackened color with the appearance of a heavy build up blackened wax. There were three hallway flooring sections that had indentations approximately one half inches deep. One floor section was near a floor incline near the 200-nurse station and there were two sections near the middle of the hallway that contained six indented floor tiles. The indented floor tiles contained blackened debris. [...]

Inspectors wroteBased on record review, review of hospital records, review of an emergency medical services (EMS) report, staff interviews, and policy review, the facility failed to provide timely, adequate and necessary care, monitoring and treatment for Resident #52 following an acute change in condition. Actual Harm occurred on 01/31/26 at approximately 1:00 P.M. when Resident #52 started receiving shocks from his implanted cardioverter defibrillator (ICD) (a battery-powered device placed under the skin to monitor, detect, and treat life-threatening heart arrhythmias). Resident #52 sustained numerous shocks from his ICD throughout the day with no intervention by staff. Resident #52 was sent to the hospital on [DATE] around 1:00 A.M. and required emergency medications to be stabilized and was admitted to the Intensive Care Unit (ICU) for monitoring and treatment. [...]

Inspectors wroteBased on personnel record review, staff interviews, and policy review, the facility failed to ensure employed Certified Nursing Assistants (CNA) were properly licensed with the State of Ohio. This had the ability to affect all 65 residents. The facility census was 65.

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to notify the physician or non-physician provider when a resident had an acute change in condition. This affected one (Resident #52) of three residents reviewed for a change in condition. The facility census was 65.

Inspectors wroteBased on review of the medical record, staff interviews and policy review, the facility failed to ensure the residents' medical records were complete and accurately documented. This affected one (Resident #52) of three residents reviewed for documentation. The facility census was 65.

Inspectors wroteBased on medical record review, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess resident skin and failed to identify pressure ulcers until they had reached an advanced stage. This resulted in Actual Harm for Resident #40 who was admitted to the facility without pressure ulcers, was assessed to be at low risk for the development of pressure ulcers, and developed an unstageable pressure ulcer with slough (nonviable tissue which could impede wound healing) to the left buttock. This affected one (Resident #40) of three residents reviewed for pressure ulcers. The facility census was 68 residents.

Inspectors wroteBased on review of staffing schedules, staff interview, and review of the facility policy, the facility failed to ensure there was a Registered Nurse (RN) scheduled for at least eight consecutive hours daily. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure food was prepared, stored, and served in a manner to protect against foodborne illness. This had the potential to affect all of the residents residing in the facility. The facility identified one (Resident #37) who did not receive food from the kitchen. The facility census was 68 residents.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure garbage cans in the kitchen were covered. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents.

Inspectors wroteBased on observation, staff interview, review of pest control documentation, and policy review, the facility failed to maintain effective pest control in the kitchen area. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure a clean and homelike dining experience. This had the potential to affect the 11 facility-identified residents (#02, #03, #07, #18, #19, #24, #39, #48, #50, #59, #61) who ate their meals in the main dining room. The facility also failed to ensure resident rooms were clean and sanitary. This affected three (Residents #53, #62, #123) of 19 residents sampled. The facility census was 68 residents.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure care conferences were completed as required. This affected four (Residents #10, #23, #40, and #56) of five residents reviewed for care conferences. The facility failed to ensure care plans were updated following a change in condition. This affected two (Residents #10 and #48) of 19 residents reviewed for care planning. The facility census was 68.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe, functional, and sanitary environment in the common areas of the facility. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents.

Inspectors wroteBased on medical record review, review of resident fund records, staff interview, and review of the facility policy, the facility failed to transfer funds upon death to a resident's estate within thirty days. This affected one (Resident #127) of five residents reviewed for personal funds. The facility census was 68 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to properly store medications in a safe and secure manner. This affected one (Resident #62) of 19 residents sampled. The facility census was 68 residents.

Inspectors wroteBased on medical record review, resident interview, observation, staff interview, and review of the facility policy, the facility failed to ensure resident meal preferences were honored. This affected one (Resident #23) of 19 residents sampled. The facility census was 68 residents.

Inspectors wroteBased on medical record review, staff and resident interviews, and policy review, the facility failed to ensure a medication was available for administration as ordered. This affected one (#51) resident out of the three residents reviewed for medications available from pharmacy for administration. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident was free from significant medication error. This affected one (#32) resident out of the three residents reviewed for medication administration. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview, review of the facility policy, and review of guidelines per the National Pressure Injury Advisory Panel (NPIAP), the facility failed to thoroughly assess residents' skin and to implement interventions to prevent the development of pressure ulcers and failed to initiate prompt and timely treatment for a resident with pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). [...]

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure nursing staff communicated with resident physicians regarding significant changes in status. This affected one (Resident #14) of three residents reviewed for notification of change. The facility census was 64 residents.

Inspectors wroteBased on record review, observations, staff interviews and policy review, the facility failed to ensure a resident's enteral tube feeding orders were implemented as ordered. This affected one (#82) of three residents reviewed for enteral tube feeding. The facility census was 68.

Inspectors wroteBased on medical record review, observations and staff interview, the facility failed to ensure medications were administered as physician ordered, resulting in three medication errors out of 31 opportunities or a 9.67 percent (%) medication error rate. This affected one (#80) of three residents observed for medication administration pass. The facility census was 68.

Inspectors wroteBased on review of staffing agency information, review of facility census, staff interview, staffing agency personnel interview, and review of the State of Ohio Nurse Aide Registry, review the Office of Health Assurance and Licensing (OHAL) website, the facility failed to ensure an aide had completed an approved nurse aide training and competency evaluation program (NATCEP) before working the facility. This affected one (Agency Aide #150) of three personnel files reviewed and had the potential to affect all 66 residents residing in the facility. The facility census was 66. Findings Include: Review of staffing information provided by the facility and a staffing agency revealed Agency Aide #150 worked in the facility from 09/13/23 through 12/22/23. Review of the State of Ohio Nurse Aide Registry revealed Agency Aide #150 was not registered as an state tested nursing assistant (STNA). [...]

Inspectors wroteBased on review of personnel record, staffing schedule information, review of facility census, staff interview, and review of the State of Ohio Nurse Aide Registry, the facility failed to ensure a state tested nursing assistant's (STNA) registration was not expired. This affected one (STNA #130) of three personnel files reviewed and had the potential to affect 17 (#39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, and #55) residents that STNA #130 regularly cared for. The facility census was 66. Findings Include: Review of STNA #130's personnel file revealed a hire date of [DATE]. Review of the State of Ohio Nurse Aide Registry revealed STNA #130 was not eligible to work in a long-term care facility due to not having work verification in the past 24 months. STNA #10's nurse aide registration expired on [DATE]. [...]

Inspectors wroteBased on medial record review, staff interview, and review of facility policy, the facility failed to complete pressure ulcer treatments as ordered. This affected three (#1, #4, and #5) of three residents reviewed for pressure ulcer care. The census was 69.

Inspectors wroteBased on medial record review and staff interview, the facility failed complete urinary catheter care as ordered. This affected three (#1, #4, and #5) of three residents reviewed for urinary catheters. The census was 69.

Inspectors wroteBased on review of time punches, daily staffing sheets, and staff interview the facility failed to ensure there were Registered Nurses (RN) working seven days week for at least eight hours a day. The affected all the residents who resided at the facility. The census was 62.

Inspectors wroteBased on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, medical record reviews, review of COVID-19 guidance from the Centers for Disease Control and Prevention (CDC), observation, review of the facility's Coronavirus (COVID-19) policies, and staff interviews, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy on 07/23/22 when Resident #153, who was mobile and left her room frequently, was not placed under quarantine upon being notified Resident #153's roommate (Resident #01) tested positive for COVID-19 in the emergency room (ER) at the hospital. [...]

Inspectors wroteBased on staff interview, observations, and facility policy review, the facility failed to ensure food and pans were stored in a safe and sanitary manner. This had the potential to affect all but one resident who was identified to not receive food from the kitchen. The facility census was 55.

Inspectors wroteBased on medical record review, staff and resident interview, observations, and policy review, the facility failed to ensure residents' call lights were within reach. This affected three residents (#17, #35, and #199) of three residents reviewed for call lights. The facility census was 55.

Inspectors wroteBased on staff interview, resident interview, medical record review, review of facility self-reported incidents, and facility policy review, the facility failed to report allegations of abuse to the State Survey Agency. This affected one (Resident #34) out of one resident reviewed for abuse. The facility census was 55.

Inspectors wroteBased on staff interview, resident interview, medical record review, review of facility self-reported incidents, and facility policy review, the facility failed to investigate allegations of abuse. This affected one (Resident #34) out of one resident reviewed for abuse. The facility census was 55.

Inspectors wroteBased on staff interviews, observations, medical record review, and review of the facility's policies, the facility failed to complete weekly skin assessment and implement preventative pressure ulcer interventions as physician ordered. This affected one (Resident #42) of four residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers and 56 residents with preventative skin. The facility census was 55.

Inspectors wroteBased on staff interview, family and resident interview, observations, medical record review, and facility policy review, the facility failed to provide nutritional supplements as physician ordered for a resident receiving dialysis treatment. This affected one (Resident #47) of one resident reviewed for dialysis. The facility identified one resident receiving dialysis services and 20 residents who receive nutritional supplements The facility census was 55.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to follow a resident's physician orders for oxygen use. This affected one (Resident #47) of one resident reviewed for respiratory services. The facility identified 10 residents receiving respiratory services. The facility census was 55.

Inspectors wroteBased on staff interview and medical record review, the facility failed to notify the resident and or the resident's representative, in writing, of the transfer or discharge and the reason for the move in writing. This affected two (#25 and #62) out of two residents reviewed for transfer and discharge. The facility census was 64.

Inspectors wroteBased on medical record review and staff interview the facility failed to send Resident #25 and Resident #62, and or their representative, a bed hold notice explaining the duration of days of the bed hold policy. This affected two (#25 and #62) out of two residents reviewed for transfer and discharge. The facility census was 64.