AVON, Ohio — Less than three months after moving into an Avon assisted living facility, Garrett Murray was hospitalized. But even after the Ohio Department of Health substantiated what went wrong, the facility faced no consequences.
Just ten weeks after moving into St. Mary of the Woods, Murray was hospitalized in January 2021.
Medical records show the then 88-year-old widower had severe hypothyroidism, which can be life-threatening, especially in the elderly.
He was so ill, his family feared he wouldn't survive.
"We thought he was done," said his daughter, Nora. "We gathered around his bedside and told him that 'It was okay, he could go be with my mom."
A survey by ODH, which licenses senior care facilities, found the assisted living facility "in compliance" and "no licensure violations were cited" after Nora filed a 12-page complaint about her dad's care.
But News 5 Investigators found the facility failed to provide crucial services Murray had paid to be provided to him.
What ODH substantiated
After reviewing the Surveyor Worksheet Notes completed by two ODH surveyors who inspected the facility in May, News 5 Investigators found the state substantiated two allegations that St. Mary of the Woods failed to provide proper care to Murray, including a failure to document whether Murray received prescribed medication to manage his thyroid condition.
One surveyor "substantiated" that St. Mary of the Woods "failed to accurately document the administration (or lack of administration) of resident medications."
The surveyor also noted a review of Murray's medication charts "revealed missing signatures."
"Somebody - we don't know who - somebody put initials in the boxes for days and times that my father wasn't even in the facility," Nora said.
The worksheet also said during Murray's stay, the facility used paper logs to record when residents were delivered their medications and that the facility changed its system prior to the survey, stating, "staff no longer records medication administration info on paper, it is all electronic."
The other substantiated allegation involves how the facility handled falls. The allegation said it "failed to provide the care and services to reasonably prevent resident falls and provide timely care thereafter" and "resident falls (were) not properly recorded in the incident log."
Prior to his hospitalization, Nora said her father fell inside his apartment on Dec. 30, 2021. She said he then laid on the floor for approximately three hours, waiting for help.
What the expert said
"The accountability measures that we have in place are not really sufficient," said Loren Anthes, a health policy expert with the Center for Community Solutions, a Cleveland think tank.
"For the most part, it's a regulatory structure designed and paid for by the industry," he said.
Anthes said the senior care industry provides significant political contributions to lawmakers in both parties in the Ohio General Assembly. As a result, he said, "Both parties have a history of doing a lot of what the industry has outlined for them."
"We are valuing the opinion of the businesses and the folks making money in the system and not the people who are relying on the services," he said.
ODH response
The Ohio Department of Health declined multiple requests for an on-camera interview.
In an email, ODH Public Information Officer Ken Gordon wrote the following:
"The Ohio Department of Health (ODH) cannot comment on an individual complaint. We can explain, in general, how our complaint survey process works. There are many factors that go into the decision whether to cite a facility. One factor, for example, is whether the facility has taken steps to correct a possible violation between the time the incident(s) listed in the complaint occurred, and when an ODH surveyor visited the facility. Using this example, it is possible for an allegation to be substantiated, yet not rise to the level of issuing a citation."
St. Mary of the Woods responds
Atrium Centers Inc, which owns St. Mary of the Woods, also declined requests for an on-camera interview.
In response to our questions about the surveyor substantiating two allegations related to Garrett Murray's care, Megan Schardt, director of sales and marketing, wrote the following:
"Thank you for the additional information, we will opt to refrain from an interview. As you are likely aware, this was a complaint surveyed by the state of Ohio and found to be unsubstantiated. With consideration of privacy for this patient and in support of our team, we feel there are no additional details to disclose."
In the Surveyor Notes Worksheet, a surveyor wrote a St. Mary of the Woods employee said, "they are doing everything in their power to properly care for their residents." and the "biggest problem is staffing."
What an industry rep said
"The state is doing plenty to make sure all facilities comply with the regulations," said Peter Van Runkle, executive director, Ohio Health Care Association, one of the largest lobbying groups for the senior care industry in Ohio.
He said ODH surveyors often do not issue citations when they substantiate allegations.
"That happens fairly regularly," he said. He blamed the "terminology of substantiated versus a regulatory violation," which he described as "confusing."
"When the surveyors come on site, they look at the whole picture," he said. ""There can be a lot of shades of gray in any situation."
What happened next
"What do you have to do to actually get cited or fined?" asked Nora. "Actually kill somebody?"
After two weeks in the hospital, Murray's family moved him to a Lakewood facility, where he lives today.
Nora said her father then spent 100 more days recovering in its skilled nursing care center.
He celebrated his 89th birthday this summer.
But Nora said she noticed the incident at St. Mary of the Woods "slipped him into a deeper state of dementia."
"The sad thing is that it was a great place," she said. "We know personally so many families that had great experiences there and I'm sad that they're no longer that place."
She is even more "disgusted" with the ODH's failure to hold the facility accountable for making so many critical errors.
"If there's an industry where there's no consequence, how can we ever be assured our loved ones are being taken care of the way we are hoping they are?" she said. "Whose side are they on?"
