EDGERTON, OH. Resident #56 had no toilet paper in her bathroom when federal inspectors arrived on December 23, just hours before the housekeeper assigned to restock her room was scheduled to end her shift.
The bathroom situation at Park View Care Center had been deteriorating for weeks. Residents complained repeatedly about dirty toilets, but the housekeeping manager claimed she never heard about any problems.
Inspectors found brown substance coating the exterior front of Resident #54's toilet, stretching approximately two inches in length. Inside the bowl, darker brown speckled material covered the back wall in a patch about two inches in diameter. LPN #201 confirmed what inspectors observed and said residents had been complaining about bathroom cleanliness.
The infection preventionist told inspectors that staff and residents had been reporting cleanliness concerns to her since early November. She said she passed these concerns up to the administrator.
But when inspectors interviewed Housekeeping Manager #400 that same day, she insisted she had received no concerns about the cleanliness of resident rooms.
The contradictions ran deeper. The Director of Nursing acknowledged hearing complaints about unclean toilets and said she reported her concerns to the housekeeping department. She claimed the concerns were "always addressed."
Yet residents kept complaining.
CNA #102 confirmed some residents complained about bathrooms and toilets not being cleaned. CNA #103 told inspectors she had her own concerns about the lack of housekeeping in resident rooms.
The problems weren't new. Resident Council meeting minutes from October 28 showed residents questioning what tasks housekeeping was expected to perform. The housekeeping manager responded two days later with a form listing daily bathroom cleaning among required duties.
By November 18, specific residents were complaining their floors weren't getting clean, according to council meeting minutes.
On December 23, Housekeeper #401 still needed to clean resident rooms on the memory care unit before her 2:00 PM shift ended. Her assignment included both Resident #56's room, where inspectors found no toilet paper, and Resident #54's room, where they discovered the brown substances.
When inspectors asked the housekeeping manager about Resident #56's empty toilet paper dispenser, she confirmed that if Housekeeper #401 had properly restocked the bathroom, there should have been an adequate supply of toilet paper.
The housekeeping daily checklist clearly outlined duties including checking and refilling supplies and cleaning the commode and base.
Resident #56, who has schizoaffective disorder, depression, and auditory hallucinations but intact cognition according to her quarterly assessment, told inspectors she had no toilet paper in her bathroom. She had been admitted to Park View Care Center in November 2024.
The facility's own policies required bathroom cleaning, supply restocking, and commode cleaning. Staff knew residents were complaining. The infection preventionist was escalating concerns. The Director of Nursing was aware of problems.
But residents continued finding brown substances on their toilets and empty toilet paper dispensers in their bathrooms.
The inspection occurred on Christmas Eve as part of a complaint investigation. Federal inspectors classified the violations as minimal harm with few residents affected, but the pattern of ignored complaints and contradictory staff statements suggested deeper problems with basic sanitation protocols.
Resident #54 and Resident #56 both used their respective restrooms regularly, according to the Director of Nursing. They depended on housekeeping staff to maintain clean, properly stocked bathrooms.
Instead, they got brown substances on toilet bowls and empty toilet paper dispensers while managers claimed they never heard about any problems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park View Care Center from 2025-12-24 including all violations, facility responses, and corrective action plans.