Brookdale Wooster

Based on interviews and review of personnel files, the facility failed to ensure staff were checked against the Nurse Aide Registry upon hire. This had the potential to affect all residents residing in the facility. The facility census was 47.

Findings include:

1. Review of the personnel file for Licensed Practical Nurse (LPN) #302 revealed a hire date of 01/12/26. Continued review of the file revealed no documentation of the Nurse Aide Registry being checked prior to the hire date.

2. Review of the personnel file for Certified Nursing Assistant (CNA) #303 revealed a hire date of 02/07/26. Continued review of the file revealed no documentation of the Nurse Aide Registry being checked prior to the hire date.

3. Review of the personnel file for CNA #304 revealed hire date of 02/07/26. Continued review of the file revealed no documentation of the Nurse Aide Registry being checked prior to the hire date.

4. Review of the personnel file for Resident Caregiver (RC) #305 revealed a hire date of 02/02/26. Continued review of the file revealed no documentation of the Nurse Aide Registry being checked prior to the hire date.

Interview on 04/02/26 at 10:15 A.M. with the Business Office Manager (BOM) #306 verified that no Nurse Aide Registry verifications were done upon hire. BOM then stated she checked them but did not print them off.

Interview on 04/02/26 at 10:20 A.M. with Health & Wellness Director (HWD) verified that all staff were to be checked against the Nurse Aide Registry prior to hire and should have documentation of this in their personnel file.

Based on observations, closed medical record reviews, staff interviews, Certificate of Death review, review of hospital documentation, review of Resident Assessment Sheets, and review of the Night Checks policy, the facility failed to ensure the safety and well-being of all residents in the facility. This resulted in Real and Present Danger and actual harm/resident death on 07/04/25, when Resident #47 was left without staff assistance from 07/04/25 from 8:30 P.M. until 07/05/25 at 7:40 A.M. Resident #47 was found in her room lying on the floor with her head stuck between the coffee table leg and wall. She was extremely white, her eyes were shut, and she was struggling to breathe. Dried clotted blood was observed on the resident floor and windowsill. Resident #47 was immediately transported to the hospital and then to a hospice facility where she eventually passed away due to blunt force trauma to the head due to a fall with a head strike. This affected one (Resident #47), resident with the potential to affect an additional 42 residents who the facility identified as needing night shift checks every two to four hours. Three additional residents (#5, #8, #26) were reviewed who required staff assistance with transfers when activating the call light. The facility census was 46.

On 07/23/25 at 4:45 P.M. the Executive Director (ED) and Director of Nursing (DON) were notified Real and Present Danger began on 07/04/25, when Resident #47 failed to receive her scheduled night checks and bathroom assistance checks, resulting in untimely assistance after a fall leading to death due to blunt force head trauma.

The Real and Present Danger was abated on 07/28/25, when the facility implemented the following corrective actions:

On 07/10/25 prior to their shift the Executive Director separated from employment the associates involved.

On 07/24/25 ending at 6:30 P.M. the Health and Wellness Coordinator or designated nurse conducted skin assessments on all assisted living residents to assist in identifying any resident potentially impacted by the deficient practice. There were no concerns noted from these assessments.

On 07/25/25 the Executive Director or designee completed interviews with all assisted living residents to identify if there were any other residents impacted by the deficient practice. No additional residents were affected. During interviews it was verified that all call lights for residents were within reach. Resident #48 was also identified as someone that could have been affected but was discharged from this facility on 07/11/25.

The Executive Director and designee completed education to the clinical associates, including care partners and nurses, on the community's Night Checks Policy, including the requirement to document the refusal to receive a night check in the resident's progress notes. The meetings were held in-person on the following dates: 07/16/25, 07/25/25, 07/26/25. Any associate who did not attend in person training, will not be permitted to provide resident care until re-education is complete.

The Executive Director and designee completed re-education to the clinical associates, including care partners and nurses, on the community's Activities of Daily Living Care Documentation Policy and Re-education to ensure call light pendants are with residents or their call lights are within reach. The meetings were held in-person on the following dates 07/16/2025, 07/25/25, 07/26/25. Any associate, who does not attend one of the above meetings, will not be permitted to provide resident care until re-education is complete.

Beginning the month of August 2025, the Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will randomly pick five assisted living residents to interview each month for the next three months to verify that night checks; emergency response times are in compliance with the community's policies and verify pendants or call light is within reach.

The Executive Director, Health and Wellness Director and designee have created a care profile binder accessible to care partners and nurses. The care profile will be used by associates to identify assigned care needs of each resident. If an assigned care need is not performed in accordance with the care profile binder, the care partner will report this situation to the nurse on duty. This nurse will follow up with the resident and the Health and Wellness Director and Executive Director.

On 07/25/25 The Executive Director or designee educated all resident care and nursing staff on utilizing the residents care profile. The meetings were held in-person on the following dates 07/16/2025, 07/25/25, 07/26/25. Any associate, who does not attend one of the above meetings, will not be permitted to provide resident care until re-education is complete.

By 07/27/25 at 9:24 A.M. the Executive Director or designee interviewed all Resident Care Associates and nurses who have provided care in the affected unit to identify if there are any other residents who may have been impacted by the deficient practice. Any associate who could not be interviewed will not be permitted to provide resident care until interview is completed.

On 07/28/25 Executive Director and designee reviewed night shift assignment sheets to ensure updated changes as necessary for all residents. Noted all residents on the assignment sheets and care needs are appropriate at this time.

On 07/28/25 All care associates will use an assignment sheet and Assisted Living Shift report. The Shift report will reflect the resident and that staff have received assignment sheets. All care associates will sign shift report- followed by review from the nurse. Starting on 07/28/25 Assisted living shift report will be reviewed daily by Health and Wellness director or designee.

On 07/28/25 the Executive Director or designee will educate all resident care and nursing staff on utilizing the resident's assignment sheet and Assisted Living shift report. Any associate, who does not receive training this date will not be permitted to provide resident care until re-education is complete.

On 07/28/25 Executive Director or designee updated the training checklist to include signing off staff received education on the night check policy, assignment sheets, care profiles and assisted living shift report for all new associates.

Beginning the week of 07/28/25, the Executive Director or designee will conduct an audit of resident call system response times three times weekly for ninety days to verify that the response times are in compliance with the community's policy.

Starting on 08/01/25 the Executive Director or designee will complete an audit on three Assisted Living Shift reports weekly for 90 days.

Although the Real and Present Danger was removed on 07/28/25, the violation continued as the facility is still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance.

Findings include:

Review of the closed medical record for Resident #47 revealed an admission date of 01/29/21, with diagnoses including unspecified combined systolic and diastolic heart failure, hypertension osteoarthritis, and a history of falls.

Review of Resident #47's Service Plan, dated 03/10/25, revealed the resident was oriented to person, place and time, and could communicate needs and preferences. The plan revealed the resident needed help to the bathroom, required assistance with pulling up and down her pants, assistance with handing her toilet paper and wiping from front to back, and assistance with changing protective undergarments. The resident also required physical assistance related to the inability to stand independently during bathroom tasks and is incontinent of bladder. Under escort and mobility, the plan revealed the resident had a fall in the last twelve months, used a walker as a mobility aid, and staff were to provide physical assistance to and from the dining room or community activities. The plan did not indicate how often the facility was required to offer bathroom assistance.

Review of the facility resident assignment plan for night shift (10:00 P.M. to 6:00 A.M.) revealed Resident #47 was scheduled to receive night checks and bathroom assistance four times throughout the night.

Review of Resident #47's medical record revealed no evidence Resident #47 was checked on through the night of 07/04/25 into the morning of 07/05/25 until 7:40 A.M.

Review of Resident #47's initial Post-Fall Evaluation, dated 07/05/25 at 8:03 A.M., revealed the resident had an unwitnessed fall. Resident #47 was observed in her living room in front of her recliner and window. Resident #47 stated she was tired and in pain, stating, my head hurts. she rated the pain a six on a zero to ten scale, with zero being no pain. She stated she was trying to use the bathroom. The evaluation revealed 911 was called and a bandage was applied. Notifications were made. The Post Fall Evaluation did not document whether the resident had her call light pendant, but review of the resident's nursing progress note dated 07/05/25 at 8:00 A.M. revealed her call light pendant was found on the bathroom sink in her apartment.

Review of Resident #47's Hospital Health Record dated 07/05/25 revealed the resident presented with altered level of consciousness and a fall. The narrative revealed the resident was unable to provide any history. All that was known was she was going to the bathroom and fell, hitting the back of her head. She denied pain at this time. Resident #47 was lethargic and hypoxic prior to evaluation. The paperwork revealed the hospital assessed the resident for reasons of her hypoxemia as well as injuries. Computed Tomography (CT) of the head and neck with contrast on was negative for acute injury fracture or injury. Her chest X-ray showed patchy infiltrates bilaterally. She had leukocytosis; this was consistent with infection which is probably causing her hypoxemia and probably her weakness and cause for her fall. Her troponin was elevated; this was probably a type two myocardial infarction (MI) due to her hypoxemia. Life care hospice will evaluate will the patient for intake in their inpatient facility.

Review of the facility's Self-Reported Incident (SRI), dated 07/11/25, revealed the facility investigated an allegation of neglect. The summary of the incident revealed Resident #47 was found in her apartment lying on the floor by the chair and window on 07/05/25 at 7:40 A.M. The resident was observed with a laceration on her head, and her left pinky finger was bruised and swollen. The resident stated she was trying to go to the bathroom. The resident does not know what time it was when she got up to use the bathroom. The resident did not call for assistance. The resident was sent to the emergency room (ER) at this time via 911 for further evaluations.

Review of Resident #47's Certificate of Death revealed the resident passed away on 07/15/25 with the immediate cause of death as blunt force trauma to the head due to a head strike. Pneumonia was listed as other significant conditions contributing to death but not resulting in the underlying cause given.

During an interview on 07/21/25 at 3:52 P.M., RCA #126 stated on 07/05/25 at 7:40 A.M. she walked into Resident #47 room to assist her with her morning routine. When she entered the room the resident's wheelchair legs were sticking up in the air and the resident was observed lying on the floor. Her head was stuck between the coffee table leg and the wall. She was extremely pale, her eyes were shut tight, she was hardly breathing, and blood was on the resident, the floor, and the window. The blood appeared dry. RCA #126 stated she used her walkie talkie to call for the nurse and called again for the nurse to call 911 because it looked bad. RCA #126 stated she found Resident #47's call light pendant on her bathroom sink by the hot water faucet. Earlier that morning in shift report, RCA #100 and RCA #200 reported Resident #47 did not call all night. RCA #126 stated she thought this was unusual because she is a frequent call light user and always wore her call light pendant.

During an interview on 07/23/25 at 9:12 A.M., LPN #116 stated on 07/05/25 at 7:40 A.M. she was called by RCA #126 to come to Resident #47's room with supplies. RCA #126 then called right back, stating to call emergency services. When she arrived at the room, Resident #47 was on the floor, her fingers were purple and appeared to be mottling. She was blowing air out of her mouth struggling to breathe. Her oxygen level was 51 percent on room air. She appeared tired. Her head was in between the recliner and the leg of her coffee table. Dry clotted blood was on the resident's head, the carpet, and the windowsill. LPN #116 stated she was trying to keep the resident awake and praying the EMTs to arrive quickly. LPN #116 stated Resident #47 told her she had been like this all night long. LPN #116 stated based on her observation, she also felt the resident had been down for quite some time. She reported her concerns that morning to Health and Wellness Coordinator (HWC) #102.

During an interview on 07/21/25 at 1:52 P.M., RCA #100 stated she worked from 07/04/25 to 07/05/25 from 10:00 P.M. until 6:00 A.M. and was told she would be training with RCA #200. She stated she had only been in the assisted living twice before this shift. She obtained an assignment sheet from the breakroom, but she does not believe Resident #47 was on the sheet. She was given a census sheet by her previous trainer that documented Resident #47 will page when she needs something. She stated RCA #200 was also new to the facility and was not familiar with the residents. She was unaware she was required to check on Resident #47 four times throughout the night and Resident #47 did not page her. RCA #100 stated she did not complete any checks or provide Resident #47 any assistance during the entirety of her shift. RCA #100 stated HWC #102 called her on 07/05/25 asking her about the fall and at this time she stated she was unaware that she was supposed to check on Resident #347 through the night and told HWC #102 that she did not see Resident #47 at all during her shift.

During an interview on 07/21/25 at 4:12 P.M., RCA #200 stated he worked from 07/04/25 to 07/05/25 from 10:00 P.M. until 6:00 A.M., training RCA #100. He stated he did not obtain a resident assignment sheet but instead used a cheat sheet provided to him which stated that Resident #47 will ring if she needs anything. RCA #100 stated he was a new employee and was told during his training that midnight shift does not use the resident's assignment sheets. He stated he was unaware Resident #47 required night checks and bathroom assistance four times a night. He verified at this time that he did not check on Resident #47 at all during the night.

During an interview on 07/21/25 at 6:21 P.M., LPN #300 stated he worked the night shift on 07/04/25 with RCA #100 and RCA #200. He stated he had last seen Resident #47 on 07/04/25 around 8:30 P.M. when he gave her medication. Resident #47 was sitting in her recliner at this time. He stated he was unaware Resident #47 had a fall at some point during the night until he was called and questioned about it the following day. He did not know if RCA #100 or RCA #200 checked on Resident #47 through the night or if they had their assignment sheets with them.

During an interview on 07/23/25 at 2:10 P.M., Executive Director (ED) #201 stated during her investigation it was discovered RCA #100 and RCA #200 did not obtain assignment sheets from the break room per the facility procedure. ED #201 stated the resident assignment sheets are the facility's only form of information for staff to know how often residents are to be checked on and provided bathroom assistance through the night. She stated due to the staff members not obtaining the assignment sheets, this led to Resident #47 not being checked on or provided any care from 07/04/25 at 8:30 P.M. until 07/05/25 at 7:40 A.M. when she was found on her floor and needed emergency transport to the hospital. ED #201 both RCA #100 and RCA #200 were suspended on 07/09/25 and both resigned during the investigation. ED #201 stated she did not have evidence that RCA #100 or RCA #200 were trained on resident's assignment sheets or the facility policy for night checks.

Review of the facility policy titled Night Checks Policy, revised February 2025, documented resident care staff should make night checks of the residents. Associates should perform night checks approximately every four to six hours or as determined by the residents' needs. When performing a night check, associates should open the door to the resident's apartment quietly and observe the resident from a reasonable distance. Assistants should be provided as necessary.

This violation represents non-compliance investigated under Master Complaint Number OH00167624 and Complaint Number OH00167601.

Based on interview and record review, the facility failed to complete annual fall risk assessments for five residents (#2, #4, #22, #26, and #30) who resided in the building for more than one year. This affected five residents (#2, #4, #22, #26, and #30) of five resident records reviewed. The facility census was 41.

Findings include:

1. Review of the medical record for Resident #2 revealed an admission date of 03/23/22 with diagnoses including Parkinson's disease, basal cell carcinoma of skin right lower limb, including hip, hypercholesteremia, depression, chronic kidney disease, and gastroesophageal reflux disease.

Review of the medical record on 04/23/25 revealed there was no annual falls risk assessment completed for Resident #2 in the last year.

2. Review of the medical record for Resident #4 revealed an admission date of 11/21/22 with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, polyneuropathy, unspecified, hypothyroidism, unspecified, and altered mental status, unspecified.

Review of the medical record on 04/23/25 revealed there was no annual falls risk assessment completed for Resident #4 in the last year.

3. Review of the medical record for Resident #22 revealed a re-admission date of 09/29/23 with diagnoses including unspecified combined systolic and diastolic heart failure, hypothyroidism, heart failure, unspecified, major depressive disorder, recurrent, unspecified, and unspecified macular degeneration.

Review of the medical record on 04/23/25 revealed there was no annual falls risk assessment completed for Resident #22 in the last year.

4. Review of the medical record for Resident #26 revealed an admission date of 12/19/22 with diagnoses including malignant neoplasm of colon, hyperlipidemia, and chronic obstructive pulmonary disease, unspecified.

Review of the medical record on 04/23/25 revealed there was no annual falls risk assessment completed for Resident #26 in the last year.

5. Review of the medical record for Resident #30 revealed an admission date of 05/03/21 with diagnoses including cerebellar stroke syndrome, hyperlipidemia, paroxysmal atrial fibrillation, hallucinations, hypothyroidism, and vascular dementia.

Review of the medical record on 04/23/25 revealed there was no annual falls risk assessment completed for Resident #30 in the last year.

Interview on 04/23/25 at 1:53 P.M. with the Health and Wellness Director revealed an annual falls risk assessment was not completed in the last year for Residents #2, #4, #22, #26, and #30. The Health and Wellness Director reported she did not know an annual falls risk assessment was needed.