A January inspection of the Pamela Shay Angel Arms Family group home, where two residents were found unconscious last week and later died, revealed 29 violations, according to the Ohio Department of Health.
The violations included inadequately trained staff and failure to provide a clean, healthy environment, among others, the agency said.
The group home at 1577 Bow St., off Western Avenue in South Toledo, housed three people with mental illnesses.
John Jones, 79, died Monday in the University of Toledo Medical Center, the former Medical College of Ohio Hospital. His temperature was measured at 105.5 degrees when he arrived at the hospital a week earlier, Dr. Diane Barnett, a Lucas County deputy coroner, said.
His roommate, Thomas Calhoun, 47, was pronounced dead about 1:15 p.m. June 9 when police went to the home on a report of two unresponsive males.
Authorities said the temperature inside the room was measured at more than 90 degrees.
The third person, a 60-year-old man, no longer lives at Angel Arms.
Pamela Shay, who owns Angel Arms, said yesterday she was devastated by the deaths. "I never intended this. It happened and I can't undo it."
Ms. Shay, a registered nurse, said it was her dream to open a group home to provide patients with better care than they receive in state-run facilities. She works full-time at a nursing home.
"I didn't feel like people were getting the care they needed," she said.
Mr. Calhoun had lived in the home for two years; Mr. Jones moved in about six months ago.
"They loved it here," she said, adding that relatives of both men visited frequently.
The state health department inspects adult-care facilities every two years, but visits them yearly to make sure they are complying with guidelines set forth by the state.
They also investigate any complaints filed against the facilities, said Sara Morman, a department spokesman.
During the January inspection at Angel Arms, state officials said there was food-stained carpet, dirty dishes in the kitchen sink from the night before, ceramic tiles missing in the kitchen, and large piles of rugs in the laundry room that created a fire hazard, a 21-page report shows.
Two employees were found to be inadequately trained.
The state health department requires the manager and each staff member of an adult-care facility to have a minimum of six hours of training in topics relevant to people diagnosed with mental illness.
The inspection revealed that one staff member lacked training and another employee had only four hours of training within the last year.
The employee with no training also was observed dropping medication on the floor and then administering it to two patients, according to the report.
State officials reported seeing "cob webs hanging all over the facility, especially in the dining room," and said there were two beds that had soiled sheets, according to the report.
Ms. Morman said the state notified Angel Arms in April that it would be fined if it didn't correct the violations. The state returned to the facility May 28 for a follow-up investigation and Ms. Morman said all the necessary changes had been made.
Ms. Morman declined to comment on the severity of the violations because the health department is a regulatory agency.
"We try not to draw comparisons between different facilities," she said. "I've seen some nursing home surveys that are 200 pages long [and] I've seen some that are 5 to 10 pages long."
Dr. Barnett said the preliminary cause of death for Mr. Calhoun and Mr. Jones, each of whom suffered from schizophrenia, was complications from heat stroke. The exact cause is pending results of toxicology and other tests, she said.
Toledo police Detective Jeff Clark, who is investigating the case, said charges are pending final autopsy results.
The men were taking anti-psychotic medication, which Dr. Barnett said increases the risk of heat stroke. The medication impairs the body's ability to regulate its temperature.
A witness identified as John Paul Jones, 42, reported to police that he checked on Mr. Calhoun and Mr. Jones about 11 a.m. June 9 and said they were both snoring. Ms. Shay found Mr. Calhoun deceased about two hours later and began CPR, according to an incident report filed by Ms. Shay.
Authorities said the men were found at least 8 to 15 hours after they became incapacitated.
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