The Lucas County coroner ruled the death of a nursing home patient a homicide, but nearly two years later, the facility continues to operate despite a long history of violations.
Patricia Sesevich, 80, died on Sept. 30, 2022, from an untreated pressure ulcer that got infected after the nursing home staff at Ridgewood Manor in Maumee didn’t treat her wound, according to records obtained from the Centers for Medicaid and Medicare Services.
The Ohio Department of Health’s investigation of the incident, completed on Jan. 5, 2023, concluded Ridgewood Manor “failed to perform timely and adequate skin assessments, failed to initiate pressure wound treatments and interventions, and failed to administer antibiotic medication as ordered for [Mrs. Sesevich], leading her to die from ‘bacterial sepsis due to a sacral pressure ulcer as a result of medical neglect.’”
“It’s not uncommon for these wounds to happen. However, it’s not OK for health care teams to ignore them,” Lucas County Coroner Dr. Thomas Blomquist said.
Dr. Blomquist said in cases like these, it takes a “considerable” amount of evidence before the lack of care is considered neglect.
According to Mrs. Sesevich’s death certificate, her death was because of “failure by caregivers to give adequate, timely medical care for the sacral pressure wound.”
“We see plenty of people that come through our office with these wounds, but you see the effects of a care team doing their best to clean it,” Dr. Blomquist said. “They recognize that, they document it, and they do their best, but it doesn’t always heal because, sometimes, people are really sick and frail, and their body won’t recover.”
Based on the information he has, Dr. Blomquist said the person in charge of Mrs. Sesevich decided not to act on her plan of care, and that lack of care led to her death. State investigators, though, did not file charges.
“Part of taking care of elderly people is that we make sure that those wounds don’t happen,” he said.
A history of problems
CMS records show that Mrs. Sesevich’s case is one of several violations Ridgewood Manor has received since 2021. The agency designated it a “special focus facility,” a label given to nursing homes with a long history of violations.
Ridgewood Manor is one of five nursing homes in the state to be classified as a special focus facility.
On top of failing to treat pressure ulcers, records show such incidents have occurred several times over at least four years. The facility has repeatedly failed to record changes in a resident’s health status, administer the correct medications to a resident, or give residents the coronavirus vaccine.
In a statement to The Blade, the nursing home said it is working to improve but did not respond to questions about Mrs. Sesevich.
“Ridgewood Nursing Home has made substantial improvements in addressing past violations by enhancing staff training, upgrading facilities, and implementing best practices in patient care,” the statement said. “The facility is committed to maintaining adequate staffing levels, ensuring timely responses to resident needs, and fostering a supportive environment for both residents and staff. Overall, Ridgewood is dedicated to continuous improvement and providing high-quality care to all its residents.”
The Lucas County Sheriff’s Office initially handled the death investigation involving Ms. Sesevich, but it was turned over to the Ohio Attorney General’s office, which handles cases related to nursing homes.
After an investigation that included a series of interviews with facility staff, family, and friends of the resident, a deputy county coroner, and an analysis of the facility and hospital medical records related to the resident, it was determined that there was not enough evidence to prove criminal neglect and the case was closed last month, said Dominic Binkley, deputy press secretary for the attorney general’s office.
Mrs. Sesevich’s family could not be reached for comment.
Each violation the nursing home has garnered has been corrected by the home, according to the plan of correction documents Ridgewood Manor submitted to CMS and the Ohio Department of Health.
However, with each inspection, the home continues to rack up more violations, referred to as deficiencies.
In a report completed on Jan. 25 following a standard survey or inspection, a similar incident affected three of Ridgewood Manor’s residents, designated as resident #213, resident #27, and resident #22.
A medical assessment for resident #213, conducted on Jan. 18, for instance, concluded they were at risk for skin breakdown.
The same day, it was observed from a shower assessment that both of the resident’s heels were damaged, the right heel sustaining a “discolored area with intact skin,” and the left heel being described as soft.
Though the right heel was treated by staff, they failed to treat the left heel, leading the wound to gradually get worse, progressing from a stage one pressure ulcer to deep tissue injury, which is defined in the report as a “purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.”
Not only was resident #213’s wound not treated properly; there was no documentation upon admission of “any documented skin breakdown,” according to the CMS report.
Residents speak up
Two residents, who still live in Ridgewood, are not surprised that the facility is on the special focus list.
When current resident Veronica Lovett came out of a coma, she found herself lying on a hospital bed at Ridgewood Manor.
She was admitted after brain complications, living at the nursing home for a year and a half, she said.
“It’s bad,” Ms. Lovett said of the conditions.
At the beginning of each day at Ridgewood Manor, she said, the quality of care starts strong when the first shift of nurses and nurse’s aides arrive to work in the morning.
When the second and third shifts arrive, that quality of care goes “downhill” from there, she said.
“[First shift] is the only good shift they have,” Ms. Lovett said.
One morning, Ms. Lovett said she wanted to get up at 6:40 a.m. to take the bus to church at 8:40 a.m.
When she asked a staff member to help her get dressed, Ms. Lovett said the nurse told her, “I’m the only one working in the whole building.”
“How does one person take care of so many people," she said. “That’s not fair.”
The Ridgewood Manor resident said it often takes a while for nurse’s aides to report to her room after she activates her call light.
“If you push your call light at six o’clock, they’ll come at eight o’clock or nine o’clock [p.m.] and put you to bed,” she said. “I don’t understand that mess.”
Fellow resident Cherie Searles has been in that situation before, her son, Fred Kline, said.
Ms. Searles said she was admitted into the nursing home in 2018 because she has difficulty walking. She said Ridgewood was “nice” when she moved in, but “now it’s getting bad.”
“Some of the aides are mean,” Ms. Searles said. “I had one make me go in the bathroom and dress myself without any help.”
Her son is frustrated at the care his mom is receiving.
“She’s supposed to be in a secure and safe place, and that’s not it. ... My mom means a lot to me,” he said. “We had our ups and downs when I was a child, but my mom means a lot to me. ... I have children. I have grandchildren. They love her. We love her.”
How homes are ranked, reviewed
Christopher Stieben, director of the Long-Term Care Ombudsman Program at Advocates for Basic Legal Equality Law, or ABLE Law, said there are many factors to consider when it comes to the quality of care in a nursing home.
“Typically, [the Ohio Department of Health] will take the five-star rating from CMS and then it will take the number of surveys or citations within their surveys in the last three years,” he said.
A nursing home having some citations is “as common as running a stop sign and getting a speeding ticket,” Mr. Stieben said.
Because there are so many people within a nursing home, including the nursing staff as well as the residents, things “might get missed” now and then, he said.
The normal citation number is around six or seven, he said.
If a facility has double that, say 12 to 14, within three years, the Ohio Department of Health will consider whether or not it should graduate to the special focus facility list, Mr. Stieben said.
Ridgewood received 50 deficiencies in 2023 and 17 deficiencies so far this year.
Though some nursing homes in the county have been special focus facilities, Mr. Stieben said it’s important to note that it is possible for a home to graduate off the list.
Within the past year, there have been three special focus facilities in Lucas County, he said.
Two of them, Point Place Healthcare and Rehabilitation in North Toledo and Advanced Healthcare Center in South Toledo, have moved off the list, Mr. Stieben said.
The Ohio Department of Health said it works with special focus facilities to “bring them into compliance with a goal of avoiding a situation where nursing home residents are displaced.”
The department conducts at least one survey within 15.9 months, which is the federal requirement for inspections, but will conduct complaint or follow-up surveys if a nursing home is out of compliance with CMS guidelines.
When nursing homes are out of compliance, they generally have six months from the exit date of the survey before “the provider will be required to cease operations,” the state said.
Facilities must complete a plan of correction form, which requires the nursing home to list each deficiency, how it plans to correct it, and by what date.
After the facility submits the form, depending on the violation, the post-survey revisit could be conducted onsite or via desk review.
For a nursing home to have its license revoked, it has to be determined by the director of the Department of Health that the facility “has violated any order issued by the director; is not, or any of its principals are not suitable, morally or financially to operate such an institution; is not furnishing humane, kind, and adequate treatment and care,” and “has had a long-standing pattern of violations of this chapter or the rules adopted under it that has caused physical, emotional, mental, or psychosocial harm to one or more residents.”
The department said it does not comment “on potential enforcement decisions regarding specific facilities” but did say its “enforcement efforts are an ongoing process and one that the department takes very seriously.”
“We are in regular communication with the Centers for Medicare and Medicaid about all Ohio facilities that are in CMS’ Special Focus Facility program, such as Ridgewood,” the Department of Health said. “It may be worth noting that CMS guidance to state agencies for facilities in the Special Focus program includes that, in their decisions for discretionary termination, CMS will consider a facility’s good faith effort to improve.
“Our primary focus is the health, safety, and well-being of residents. That said, ODH is serious about using the tools at our disposal to ensure nursing homes are providing a high quality of care to residents.”
The department has revoked facilities’ licenses in the past, it said, and did so on several occasions just last year, for example, and that “remains a very real option for any facility that consistently demonstrates noncompliance with state regulations.”
CMS' guidance to state agencies for facilities in the Special Focus program includes that, in their decisions for discretionary termination, CMS will consider a facility’s “good faith effort to improve.”
The department said it’s taking many steps to improve the quality of care in nursing homes following the creation of the Ohio Governor’s Nursing Home Quality and Accountability Task Force last year, which is meant to “find pathways to improve the quality of the nursing home system in Ohio.”
It added ODH is actively recruiting, training, and hiring surveyors and others who support inspection work and created the Provider Resources & Education Program, or PREP, this year, which supports nursing homes and other long-term care providers with education, training, and resources designed to improve and protect the safety, health, and quality of life for residents and others in their care.
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