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PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.


Level of harm – ACTUAL HARM

Based on observation, record review, and staff interview, the facility failed to ensure Resident #135’s medication regimen was free from unnecessary medications. This resulted in harm to Resident #135 as the resident was sedated and experienced a decline in activities of daily living related to transfers and ambulation. The resident also developed a suspected deep tissue injury (SDTI) pressure ulcer as a result in the decline in condition attributed to the use of unnecessary medication. The facility failed to ensure Resident #121 was adequately monitored related to the use of an anti-psychotic medication. This affected two residents (Resident #135 and #121) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #135 revealed the resident was admitted to the facility 02/28/14 with [DIAGNOSES REDACTED]. The resident did not have any pressure ulcers upon admission and was assessed as being at minimal risk for the development of pressure ulcers.

Continuing: The resident’s eyes were closed and his mouth open. Observation on 04/30/14 at 2:50 P.M. of the resident’s skin revealed that the resident currently had three pressure ulcers including the right outer ankle, the right buttock, and the left heel. The left heel had a four centimeter (cm) by 5.3 cm pressure ulcer with black eschar present. The resident had also developed a new two cm by 1.8 cm purple blister (suspected deep tissue injury) on the right mid outer foot which had not been identified by the facility. Review of the plan of care, dated 03/04/14 and 04/14/14 revealed the resident had a potential for side effects related to [MEDICAL CONDITION] drug use. The goal was for no negative outcomes resulting from the use of the [MEDICAL CONDITION] medications. The interventions included monitoring for periods of lethargy. Review of nurse’s notes from 04/12/14 to 05/01/14 did not reveal any documentation regarding the resident showing any signs of sedation. Interview with STNA #7 on 04/30/14 at 2:45 P.M. revealed Resident #135 had been acting more sleepy since he came back from the hospital the last time. He confirmed the resident sits with his eyes closed. Interview with Registered Nurse #2 on 04/28/14 at 2:50 P.M. revealed she was wondering if the pain medication was making Resident #135 more sleepy. She stated that after she gives him the pain medication at 9:00 A.M., then the rest of the day he has his eyes closed. She confirmed she had also given him pain medication at 2:00 P.M. Interview with Physical Therapist #3 on 05/01/14 at 9:30 A.M. revealed Resident #135 had declined in his ability to walk since admission. She stated he was able to walk initially and now can no longer walk. Record review revealed there was no evidence the physician was aware of the resident’s continued lethargy and no evidence the resident’s medications had been reviewed for possible reductions. This was verified by the DON on 05/01/14 at 10:38 A.M.

2. Review of Resident #121 ‘s clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Review of the April 2014 medication administration records revealed the resident received the medication four times in April 2014, none in March 2014, once in February 2014 and once in January 2014. Review of the consultant pharmacist report, dated 02/18/14 through 02/18/14 the pharmacist documented a recommendation for the resident to have an electrocardiogram (ECG) to monitor the side effects of the medication, [MEDICATION NAME]. The physician’s signature on 02/21/14 stated acceptance of the recommendation and to please implement the monitoring plan outlined on the form. No indication of a plan was documented on the form. Record review revealed no evidence the ECG was performed in accordance with the physician order. The only documentation of an ECG performed on the resident was dated 12/11/13, prior to the resident’s admission to the facility. On 05/05/14 at 8:21 A.M., interview with the DON revealed an ECG had not been completed for the resident following the recommendation of the pharmacist review, which was accepted by the physician in February 2014

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here or call our toll free hot line number: 1-800-645-5262

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  1. Betty Davies says:

    i for one think places like this give all nursing homes a bad name. I am thankful my parents never had to be put in one. The people responsible need to be charged with something for not doing their job, over medicating and lord knows what else. You would think the nurses aids would notice when it came time to bath the residents and report it. Evidentially they aren’t doing their job right either. I’ve told my children never put me in one of those places. Now they’ll know why!

  2. i worked at Arbors of Gallipolis,Ohio. I was employed as the residents Beautician. On more than one occasion , I was asked by The Administrater and the DON, Valerie Mayes and an office employee, Denise, to make the 3 residents wait and go ahead and take care of a resident, Patricia James’ hair. i had always complied to their requests. On the last day that I worked there the DON ,Valerie Mayes, came in the salon and demanded that the lady I had in the salon chair and the other 2 ladies wait until Pat James was taken care of. I asked if she had an appointment that she needed to go to that required “preferred treatment” in the salon and no she didn’t , so when I refused to have the resident in the chair , Barbara Fletcher,removed from the chair, Valerie Mayes,returned to the salon and demanded that I take Pat James ahead of the other 3 ladies that had already been waiting. At that point I told her {DON} that I would pack my supplies and quit, and she said just do that. I am an Independant Contractor with a valid Ohio Managing Cosmotologist’s Licence and I treat the residents very well and am very considerate of each and everyone of their feelings and well being.I didn’t feel that the resident , Pat James, required preferential treatment on that day since she was going nowhere at that time.In my opinion , the other 3 ladies in the salon were just as important. I was treated like I did something wrong and I did not. I refuse to work in a facility where residents are treated in that manner. On many occasions residents have been brought in the salon reeking from dirty Depends that I’m quit sure they have been in for too long. I as their Beautician and the residents are not treated fairly. I have been the Beautican at Overbrook Center in Middleport, Ohio for 2 years and can not say enough about the facility. It is by far the cleanest and most proficiently ran facility I have ever worked in. The residents are all treated with the utmost respect and dignity and they are offered daily activities that surpass any other facility that I have worked in. I have worked in Rocksprings Rehabilitation, Pomeroy, Ohio and it it ran in the same manner as Arbors of Gallipolis. I would not recommend either facility. If anyone needs any further information on the subject of my experience with the nursing homes in question and the treatment of the residents, feel free to contact me at 740-591-7821.

  3. This is a shame. Where was the corporate consultant that is suppose to come in and follow up frequently on what is happening in this facility?
    Where was the DON and Nurse Managers? Facilities like these only seem to get negative publicity, but working at a facility similar I understand the struggles. There has to be firm consistent validations in place or things like this happen and happen quickly. It takes a very strong team to keep a facility in top shape and ensure that nothing is slipping thru the cracks…. do I believe any of the employees intended to cause harm? Not by any means, but the lack of staff mandated by the state makes it very hard to implement systems, keep up with changes and educating your staff, and watch everything that’s going on. We like to think that the communication should be in place but all humans get sidetracked or have Murphys law episodes, and 1 small piece missing can leas to the whole big pictured painted above.
    It is very unfortunate the cites listed above, but the community should push back on the state and on corporate. Gallipolis is already a very small town that doesn’t have many places to offer the elderly, and this could potentially take away another. Corporate should put consultants in place, to identify triggers and implement systems and education that will help increase the efficiency of current staff, and the state needs to really assess the mandated patient/nurse ratio & patient/ STNA ratio. I’m not saying provide so much staff that it’s 1 on 1 care, but 9 and 10 to 1?. And that’s on the busiest shift of the day….
    Please assess all players in this and not just the facility and their staff

  4. My Grandmother was there for a year before she passed away.

  5. Tina says:

    This is sad and it really does happen every day at every nursing home. My niece works at one and she says that she something has to basically smack a doctor in the face when they don’t look and listen to her about a resident. She says it’s very frustrating. Bed sores are easily preventable when cared for from the beginning. I hope this brings awareness.

  6. Lisa Glispie says:

    My son was in this facility and WHY the state allows this place to be open is beyond me!! It NEVER smelled clean, the first time there he had MRSA and they had changed the lad off his bed and left it folded up and laying on the floor not contained in plastic bag or anything! He had MRSA septis. Pnenmonia
    Many times while there I truly believe he didn’t get food care at all and would have died if he had stayed!!! The state should REQUIRE stricter standards and when a place like this is found to be inadequate they need closed down or cleaned up and continually monitored!!

  7. Becky Triplett says:

    My mother was a patient there in the late 90’s. She was only there for a short term problem with her blood pressure. The doctor wanted it to be monitored because she was passing out when she stood. They constantly failed to follow doctor’s orders. One Saturday we were sitting in the lobby by the nurse’s station visiting with Mom and some other ladies. I heard the nurse make several calls trying to find people to work the next day.
    The next day my mother wanted to attended church services on another floor. She asked for someone to get her ready but they didn’t come so she got herself dressed. She was supposed to wear pressure hose which she could not put on herself. Walking down the hall to the elevator, my mother fell and broke her hip. The only time I ever went back there was to clean out her room. The nurse lied to me that day and told me that they weren’t short staffed and that Mom hadn’t asked for help. I guess she was afraid we were going to sue them. We should have. We were just glad to be away from that horrible place.

  8. Mary Allen says:

    That place has always been nasty. I worked on the squad years ago and would have to go in there to pick people up and take them to doctors appointments, hospitals,etc;. The place always smelled of urine terribly and the residents were always sitting slumped over out of it. They would just put them out in the hallway and leave them. One time my partner and I had to take a lady with a feeding tube to the doctor because she was in so much pain. When we got her there the doctor was so mad because they had put a wooden spring clothespin on her feeding tube and it was green and stinking. He then called straight to the nursing home and literally cursed the charge nurse and told her that they have the clamps for those and he had better never see that again. We helped the doctor to put my Lanta on the stomach to help relieve the pain as the stomach acids had made her stomach raw. Oh by the way , when we picked her up the aides had her restrained and we asked why and was told because she was combative and would hit us. She was pulling at her gown but the reason was because of the pain on her stomach, which we found out when we took her to the doctor. She could not speak so she just kept moaning and pulling at her gown . It’s totally unacceptable that this place wasn’t shut down years ago.probably because they line someone’s pickets.

    • joyce bing-white says:

      I worked there as the beautician and was treated with the most horrible disrespect that any human could ever be treated by the Director of Nursing (Valerie), from the time I started working there she badgered me until I quit. She should have been taking care of the residents that sat around with their heads slumped over in soiled depends, I would never recommend that facility to anyone. If she was taking care of her job as DON she wouldnt have had time to come in the salon.

  9. Nikki says:

    This isn’t the only facility with staffing issues. There are several but working in several as a nurse the biggest issue is this you get generation is entitled, lazy, and wants something for nothing. And when they do ha e good staff that will work, it’s the ones who call in all the time who make it hard for the ones who do show up and work. This facility is among the worst I have seen but not all the staffing is to blame. There are a few that go above and beyond to try to make a difference.
    Anyone who tells you they are not short staffed in long term care is lying. Even when full staffed, there still is not enough staff for proper care and THAT is a result of big corporations who are too tight to pay for more staffing and operate on bare minimum.

    • tammy says:

      It’s truly not the corporation. The state makes regulations and since they pay 90% of the bills they leave the companies no other choice but to work per the regs… families should get together and voice their concerns to the state about their regulations in all long term and skilled nursing facility. You have to aim at the root of the problem, not just at the facilities that have system issues


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