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Who's holding nursing homes accountable?

Mahoning Matters’ weeks-long review of area nursing home inspection reports has raised questions about the accountability measures that keep homes up to standard — or lack thereof.
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John Saulitis, director of the long-term care ombudsman program at Direction Home of Eastern Ohio in Youngstown, reviews data alongside Theresa Knapik, the program's assistant director.

[EDITOR'S NOTE: This is the final of a three-part series. To read about the issue at White Oak Manor, click here. To read more about issues at Oasis Center for Rehabilitation and Healing, click here.]

Mahoning Matters’ weeks-long review of area nursing home inspection reports has raised questions about the accountability measures that keep homes up to standard — or lack thereof.

The number of reported health and safety deficiencies at Ohio nursing homes nearly doubled between 2014 and 2018, from nearly 4,000 reported citations to about 8,000.

According to the most recent annual reporting from the Ohio Department of Health, which regularly inspects those facilities, the number of deficiencies that caused actual harm to residents — as opposed to those that only created the potential for harm — also increased steadily over that time from 187 reported citations in 2014 to 296 in 2018.

The top-five most-reported deficiencies, in order, related to: facilities’ infection prevention and control methods; quality of resident care; accident hazards or supervision; food safety; and how facilities followed abuse or neglect policies.

“In the case of abuse complaints or allegations, the numbers are not as high as sometimes people think, which is a good thing,” said John Saulitis, director of Direction Home of Eastern Ohio’s long-term care ombudsman program, which advocates for quality nursing home care and helps residents and their relatives navigate the long-term care system.

He said he’s made fewer than 20 abuse complaints to ODH in his 25 years of ombudsman work.

“[Abuse complaints] tend to get a lot of attention and they’re handled extremely aggressively … and they should be handled aggressively. But the vast majority of complaints … are dealing with quality-of-life issues,” he said.


For weeks, Mahoning Matters has reviewed inspection reports on file for the 46 Medicare- and Medicaid-certified nursing home facilities in Mahoning and Trumbull counties.

Ohio Department of Health inspectors perform at least one unannounced, on-site inspection at each such facility in the state on a 9- to 15-month cycle, as well as singular investigations after receiving complaints about their care. Those inspectors may issue citations for deficiencies in service, categorized by residents' freedom from abuse, their quality of life, nutrition and the structure or administration of the facility itself, among others. Inspectors categorize those deficiencies by their scope and severity — whether the deficiency created the risk of harm to residents or placed residents in "immediate jeopardy," and whether the deficiency was isolated or widespread.

The inspections also indicate whether deficiencies were corrected, and when.

The Centers for Medicare and Medicaid Services, which approves Medicaid licensing for nursing homes at the federal level and tracks facilities that fall short of minimum care standards, applies overall quality ratings ranging from one star to five stars to each nursing home, which can be found on the Nursing Home Compare site. The star ratings are based on each facility's health inspections, their level of staffing and the quality of their resident care measures.

The Centers also tracks abuse and neglect complaints. However, a recent federal audit of the Centers found many possible cases of abuse or neglect reported in 2016 at nursing homes nationwide weren’t properly reported to the state or law enforcement, despite federal requirements.

Mahoning Matters’ review of state inspections of nursing homes in the area found many have been cited by the state for under-reporting claims of abuse, neglect or criminal activity or for not following through on investigations into those claims.


About 1 in 5 of the “high-risk” Medicare claims coinciding with American nursing home residents’ hospital emergency room visits in 2016 were the result of potential abuse or neglect — including cases in which it’s unclear how residents got their injuries — according to an Office of the Inspector General report released in June.

The office reviewed 37,000 of those claims involving more than 34,000 Medicare beneficiaries and estimated 6,600 of them involved potential abuse or neglect.

Of a sample size of about 250 cases, investigators found 51 cases involved potential abuse or neglect that was reportable under the guidelines, but 43 of them were not reported. In another 67 cases outside the sample range, abuse was substantiated but it wasn’t reported to law enforcement.

Saulitis said a recent change in Ohio law requires nursing home facilities to involve police in criminal investigations that arise from resident complaints. Facilities are required to self-report those incidents to the Department of Health immediately, but Mahoning Matters’ review of area nursing homes found several instances where that didn’t happen, and facilities were cited for untimely reporting of allegations or for not properly investigating them, as well as other accountability failings.

In some cases, nursing home administrators told state inspectors the claims weren’t reported because they were unsubstantiated.

  • Oasis Center for Rehabilitation and Healing along East Midlothian Boulevard in Youngstown was cited in March for failing to protect a female resident from alleged sexual abuse by another male resident, as well as for not properly investigating it.
    Speaking with the inspector, the facility’s director of nursing “confirmed the facility investigation was not thorough as it did not include staff, visitor or resident interviews following the incident,” the report states. “Because the investigation was not thorough, systemic problems were not identified and corrective action was not put in place.”
    The facility’s investigation ultimately deemed the abuse allegation unsubstantiated.
    “[The director] did not feel abuse occurred, and from this point forward he indicated he would not report allegations if he did not feel they would be substantiated,” the report states. “The [director] also indicated he based his reporting on each resident and he would not necessarily report allegations made by a resident with dementia.”
    The facility was separately cited for not properly responding to that incident, as well as: another instance of sexual contact between different residents; an instance of nonsexual abuse involving two other residents; a claim of threatening treatment from one facility worker; and a claim of theft from a resident.
    In a December 2016 inspection, the facility was cited for failing to report an allegation of verbal abuse by a facility worker. The claim was also unsubstantiated, however, and considered “not reportable” by facility administrators.

  • White Oak Manor along Ridge Avenue in Warren was cited in August for not properly reporting three residents’ allegations that they were each sexually abused by one resident. That resident was described in the inspection as having “ a documented history of anger and violence issues.”
    Although a medical director told the facility to watch the resident closely, the facility didn’t implement a plan to prevent him from abusing other residents, according to the inspection.

  • Greenbriar Center along South Avenue in Boardman was cited in May 2018 for not properly reporting a resident’s sexual abuse allegation to the state or the resident’s relatives or physician. One female resident reported a male employee “made her feel sexually uncomfortable” while checking to see if her undergarments were dry.
    “The administrator felt it was more of a customer service issue so she did not report it to the state agency,” the inspector noted.

  • Danridge's Burgundi Manor along Marantha Drive in Youngstown was cited in May when the inspector discovered the facility administrator had not been properly performing fingerprinting or background checks on employees. The company instead used a website to check criminal histories rather than an approved service.

  • At Beeghly Oaks Center for Rehabilitation and Healing along Market Street in Youngstown, an inspector found in July 2016 two residents had sustained injuries that seemed consistent with abuse, but those injuries weren’t properly reported to the state.

  • At Continuing Healthcare of Boardman along Boardman Canfield Road in Boardman, a September inspection identified an allegation of one male resident sexually touching another resident. The administrator reported the allegation was not identified as possible abuse, and therefore was not reported to the state.

The inspector general’s June investigation determined the Centers’ rules don’t actually require abuse or neglect claims and related law enforcement referrals to be recorded and tracked in the Center’s incident tracking system.

"One reason was that [the Centers'] guidance was not clear and, therefore, subject to inconsistent interpretation,” the report reads.

The Centers expects to finish transitioning to a new incident tracking system next year, according to the inspector general’s report.

Saulitis added many residents don’t report abuse for fear of retaliation, Saulitis said, though he added he’s never seen an instance of retaliation at area nursing homes in his career.

“Can it happen? … You can’t discount that fear,” he said.


Steve Piskor said his mother Esther was totally reliant on nursing home workers while living at Elizabeth Severance Prentiss Center along Scranton Road in Cleveland.

She couldn’t walk and spoke very little. She responded to simple, short questions like “Are you OK?” Sometimes she would say yes; other times no.

But as Piskor watched his mother interacting with her aides he could tell “she was scared.”

It wasn’t until Piskor placed a hidden camera in his mother’s room that he learned why: Esther can be seen being roughly “tossed around” by aides, one of whom jabs her in the face; another sprays something Piskor later learned was perfume in her face.

“I said, ‘Nope, that’s enough’ and I went to the police,” Piskor said.

But it wasn’t that easy. Piskor said neither Cleveland police nor the facility owner’s private police force initially acted on his evidence.

It wasn’t until he dropped off the footage at Cleveland’s WKYC-TV news station that he caught police’s attention, he said.

The case was ultimately prosecuted. The aide who struck Esther got more than 10 years in prison; another got six months. Others were fired during the ensuing investigation, Piskor said.

If Piskor hadn’t installed the camera, he said he "wouldn’t have known,” he said.

His story inspired two new bills in the Ohio Legislature. Dubbed “Esther’s Law,” the bills would allow nursing home residents to have hidden cameras installed in their rooms. Piskor himself helped draft the legislation, drawing from similar laws in Texas and Illinois, he said.

State Rep. Juanita Brent of Cleveland, D-12th, introduced House Bill 461, Esther’s Law, into the Ohio House in late December. It’s currently assigned to the House’s Aging and Long-Term Care Committee.

Its Ohio Senate companion bill, Senate Bill 255, was also introduced in late December by state Sen. Nickie Antonio of Lakewood, D-23rd, and Andrew Brenner of Powell, R-19th. It’s been assigned to the Senate’s Health, Human Services and Medicaid Committee.

According to the bill’s language, the hidden cameras aren’t required and must point away from residents who don’t want them. Still, opponents have privacy concerns.

The language also requires a sign to be placed in the resident’s room stating the room is under hidden surveillance. Some feel the need for a sign defeats the purpose.

Though she feels residents’ lawful rights already allow for them to have their possessions in their room — including cameras — she noted some nursing homes have established policies against them. They’ve been cited by inspectors for those policies, however, suggesting cameras are allowed by the health department’s regulatory ruling alone.

Piskor said he feels nursing homes and health inspectors are currently the ones who get to decide whether abuse claims will be reported and possibly prosecuted, when it should be the police.

“Who gave the Department of Health authority to investigate a crime?” he said, adding it’s almost as if nursing homes get to say, “We’re not saying this didn’t happen but we can’t do anything because we didn’t see it happen.”


During regular surveys of skilled nursing facilities, state inspectors cite for deficiencies where facility conditions or care procedures don’t meet the Centers’ standards. In the most serious cases, the facility is fined, either on a one-time basis or for each day the problem goes uncorrected.

Collected fines go into a state fund for nursing home resident protection. In fiscal year 2019, that fund sat at an estimated $4.9 million, according to the Ohio Legislative Service Commission’s review of Ohio’s biennium budget. In 2020, it’s expected to decrease nearly 20 percent to $3.9 million. A marginal increase to $4.01 million is expected for the 2021 fiscal year.

According to the most recent ODH annual report, the vast majority of deficiency penalties were fined between 2014 and 2018.

Though the state slapped Oasis Center for Rehabilitation and Healing with a more than $114,000 fine for the incident referenced above — making it the only nursing home in Mahoning and Trumbull counties to be fined a six-figure sum in the last three years — the majority of fines reviewed by Mahoning Matters were much smaller.

Beverley Laubert, Ohio Department of Aging’s state long-term care ombudsman and that department’s former director, said the department has “expressed concern” that lower-level fines don’t incentivize a facility to fix the issue.

She recalled one case in which her office advocated for a resident who was wrongfully forced to leave a nursing home. Administrators said, “We’ll just pay the fine … we’re not taking him back,” she recalled.

Ultimately the resident was allowed to return and the facility still paid a $15,000 fine, she said.

The next most-common penalty from 2014 to 2018 was a denial of payment from the Centers, but that made up only a fraction of the total cases reviewed in those years.

In that scenario, the Centers denies Medicaid payments for new facility admissions until deficiencies are improved. Residents can still move in and receive care, but the facility won’t be reimbursed by Medicaid for it.

In other cases, the department imposes in-service training for employees.


The last resort for an underperforming nursing home is termination of the facility’s Medicaid or Medicare provider agreements, which often leads to the facility’s closure as they’re largely dependent on public dollars, Laubert said. The Ohio Department of Health recommends facility license approval to the Centers, and if approved, that license is held at the state level.

The license termination process works similarly to state surveys and considers the scope and severity of a facility’s deficiencies, with extra attention paid to the most serious deficiencies which present a “real and present danger” to residents.

The former Campus Health Care Center along Colonial Drive in Liberty Township and its sister facility Cedarcreek Health Care Center along Tod Avenue Northwest in Warren closed in early 2016 and were the last two nursing homes to close down in the area, officials said.

Campus was one of the state’s Special Focus Facilities, identifying it as a nursing home with some of the worst health and safety citations in the state. Its most recent state inspections found residents with severe pressure ulcers — commonly called “bed sores” — or who were left in soiled undergarments. Some residents didn’t know whether they’d received their medications.

The Centers was prepared to revoke the facility’s health license, but the facility closed voluntarily in January of that year. Tennessee-based New Beginnings Health Care LLC, which owned both facilities, filed for bankruptcy protection earlier that month. In the days leading up to Campus’ sudden closure Jan. 28, 2016, most or all of its workers resigned, including the administrator. At the time, workers reported to media they weren’t being paid.

Though nursing homes are required to give a 90-day notice of a closure, Laubert, Saulitis and other local advocates had less than a day following the closure announcement to relocate the facility’s 44 residents.

Regardless of the circumstances of a closure, it’s still traumatic for the residents who have to leave, Laubert said.

“The reality is … there are many residents who really don’t want to leave. For better or worse, they consider that their home and we respect that,” she said. “The focus really should be on ‘can we make the facility operate properly?’ Closure is a dramatic and traumatic step for many residents who have lived there, in some cases, for decades.”


Long-term care ombudsmen like Saulitis and Laubert don’t have any regulatory power over nursing homes, but they do advocate for their residents, acting as a go-between for corporate facilities and their residents, helping to resolve care complaints and pointing consumers to the right facilities for them.

Saulitis said Direction Home of Eastern Ohio reviews nearly 1,000 complaints a year between the four counties it covers: Mahoning, Trumbull, Columbiana and Ashtabula. He said he feels his agency learns about more complaints than the Ohio Department of Health because of the personal relationships ombudsmen are expected to form with nursing home consumers — part of the Department of Aging’s “person-centered” directives.

Though by state rules ombudsmen are expected to investigate complaints by the end of the next working day, that’s “not good enough” for Saulitis’ agency — “the rule we have in this office is you go out that day,” he said.

Ombudsmen assist residents or their relatives with filing complaints and can also help them reach state oversight officials, depending on the situation.

They’re also heavily involved in the nursing home survey process. ODH is required to contact ombudsmen before nursing home surveys to learn about experiences there.

The office utilizes volunteers to visit facilities on a regular basis, talk with residents about quality-of-care issues and their rights and work with facility staff to resolve simple problems. Last week, the state put out a call for more of these volunteers, according to a release.

Volunteer ombudsman representatives receive extensive training to serve as advocates for long-term care consumers. Topics include problem-solving, interviewing, the rules and laws of long-term care and how to work with providers to honor consumers’ choices.

To apply, go to


Saulitis and Laubert agreed it’s not enough to select a nursing home based on its rating. Though those ratings offer a "snapshot" of the quality of each facility, they aren't a substitute for visiting the facility yourself, according to the Centers' website.

“If you walk into a facility and it smells bad, what more do you want to know?” Saulitis said.

He recommended reading a facility’s recent health department citations, rather than relying on the star rating to select a home for your loved one.

“Families, I think in many cases, have to be more vigilant than when the person is living in their home,” Laubert said.

In Mahoning and Trumbull counties, only a handful of nursing homes received deficiency-free inspections in the past two years: Masternick Memorial Health Care Center along Windsor Way in New Middletown, Austinwoods Rehab Health Care along Kirk Road in Austintown and O’Brien Memorial Health Care Center along Brookfield Avenue Southeast in Masury weren’t cited during their 2019 inspections; Addison Healthcare along Addison Road Southeast in Masury and The Center for Rehabilitation at Hampton Woods along East Western Reserve Road in Poland weren’t cited during their 2018 inspections.

“We always advise people to visit a facility and use all your gut instincts and senses to look at the place,” Saulitis said. “Are the rooms individually decorated by the residents? Does it look like a home or does it look like an institution? Do you see the administrator interacting actually one-on-one with residents? Do they know their residents by name?

“These seem like simple things, but it’s that ‘person-centered’ connection.”

The state ombudsman office in the coming months is expected to launch a family satisfaction survey program, which will survey families of nursing home residents on their regard for the home’s quality of care. Results will be published in the office’s Long-Term Care Consumer Guide.

“We ask, ‘Do you feel comfortable when you leave the facility that your loved one is getting the care they deserve?” Laubert said.

Piskor said relatives need to take the time to visit relatives in their nursing homes and personally check their entire body for any physical signs of abuse.

“To go in there every day doesn’t guarantee abuse doesn’t happen,” he said. “It’s worse than crisis levels. It’s happening every single day in every nursing home. There’s no nursing home that can say they don’t have abuse in them — none.”

Laubert said nursing industry workers should be continually reminded that the elderly residents aren’t living where they work — the nurses are working where those elderly live.

“If we all keep that in mind, I think that makes things easier and improves care,” she said.

Justin Dennis

About the Author: Justin Dennis

Justin Dennis has been on the beat since 2011, covering crime, courts and public education. Dennis grew up in Poland and Salem and studied journalism and communications at Cleveland State University and University of Pittsburgh.
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