The resident, identified as Resident #117, had not received blood tests to monitor seizure medication levels since January 2025. Federal inspectors found the facility ignored a September 17 pharmacy recommendation requesting lab orders every six months for seizure medications.
Pharmacist #810, who conducted monthly medication reviews, confirmed during an October 25 interview that residents on seizure medications should have labs done at least three times yearly if stable. Physician #815 agreed during a September 25 interview that residents on seizure medications, including Resident #117, should have labs checked at least a couple times per year.
The Director of Nursing confirmed during a September 29 interview that no lab work had been ordered to monitor the resident's three seizure medications since January. The resident was subsequently admitted to the hospital with what inspectors described as a "HIGH ALERT Phenobarbital level."
Phenobarbital requires careful monitoring because blood levels can build to toxic concentrations over time. High levels can cause severe drowsiness, confusion, breathing problems, and potentially life-threatening complications.
The facility's own medication policy required pharmacists to report medication irregularities to attending physicians and the Director of Nursing, with these reports acted upon in a timely manner. Urgent or significant irregularities must be communicated the same day they are observed, while non-urgent issues require response within 72 hours.
The September 17 pharmacy recommendation specifically requested physician orders for seizure medication lab monitoring every six months. The Director of Nursing acknowledged this recommendation was never addressed.
Federal regulations require nursing homes to ensure residents receive proper pharmaceutical services, including monitoring for medication effects and side effects. The facility's failure to act on pharmacy recommendations violated these requirements.
The inspection was conducted October 9, 2025, following a complaint filed as Number 2603626. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Wyant Woods Healthcare Center operates at 200 Wyant Road in Akron. The facility's medication regimen review policy states that monthly reviews will be performed by licensed pharmacists according to federal and state regulations meeting current standards of practice.
The policy specifically requires pharmacists to review and report medication irregularities, with the Director of Nursing responsible for addressing all reports with medical practitioners in a manner that meets residents' needs.
Despite having clear policies and receiving specific pharmacy recommendations, facility staff failed to ensure basic medication safety monitoring. The resident's hospitalization with toxic drug levels represents a direct consequence of this oversight.
The case highlights ongoing challenges in nursing home medication management, where complex drug regimens require careful monitoring to prevent dangerous complications. Seizure medications particularly demand regular blood work because therapeutic levels sit close to toxic levels.
Resident #117's experience demonstrates how administrative failures can directly impact resident safety. The months-long gap in required monitoring created conditions for medication toxicity that ultimately required emergency hospitalization.
The facility has not publicly disclosed how many other residents may have been affected by similar monitoring lapses or what steps have been taken to prevent future incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wyant Woods Healthcare Center from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Wyant Woods Healthcare Center
- Browse all OH nursing home inspections