Brookdale Austintown

Based on record review, observation, interview and facility policy review, the facility failed to maintain a comfortable and odor free environment. This affected two residents (#1 and #3) reviewed for environmental concerns and had the potential to affect four additional residents (#4, #7, #9 and #31) residing on the A-hall. The facility census was 31.

Findings include:

Review of the medical record for Resident #1 revealed an admission date of 07/11/24 with diagnoses of subdural hemorrhage, dementia, left artificial hip, high blood pressure and arthritis.

Review of the personal service plan dated 06/26/25 revealed Resident #1 had memory loss and was severely cognitively impaired. She was dependent on staff for all activities of daily living (ADL).

Review of the medical record for Resident #3 revealed an admission date of 07/01/24 with diagnoses of senile degeneration, high cholesterol, high blood pressure and glaucoma.

Review of the personal service plan dated 08/07/25 revealed Resident #3 had memory loss and was not always oriented to person, place or time. She was dependent on staff for all ADL.

Observation on 02/02/26 at 9:24 A.M. of Resident #3's room revealed a strong odor coming from the room. Interview at the time of the observation with Business Office Manager (BOM) #200 confirmed there was a sewage smell coming from the toilet in Resident #3's room.

Interview on 02/02/26 at 9:30 A.M. with Certified Nurse Aide (CNA) #201 and Care Professional #202 revealed there was often a sewage smell in the hallway on the A hall. They confirmed the facility was aware but had done nothing to correct the situation. Care Professional #202 also reported the maintenance man came in Resident #1's room this morning and removed ice from the pipe on the back of the toilet leading outside. She revealed the bathroom was always exceptionally cold and had been dripping water and ice for approximately one week.

Interview on 02/02/26 at 9:49 A.M. with Family Member #208 confirmed Resident #3 had been in the current bedroom for approximately one year. The sewage smell continued for that time, and the facility replaced the carpet in an effort to combat the problem.

Interview and observation on 02/02/26 at 10:28 A.M. with CNA #206 confirmed there was a foul odor coming from Resident #3's room. She was unable to identify what the odor was; however, she confirmed it was more prominent in the residents' bathroom.

Interview one 02/02/26 at 10:49 A.M. with Maintenance Technician #205 revealed he was aware of the odor in Resident's #3's room and planned on suggesting having the carpet removed but could identify no other interventions that had been put in place to identify the root cause or eliminate the smell. He admitted the smell did permeate into the hallway at times. Maintenance Technician #205 confirmed the toilet in Resident #1's room would often freeze up, and ice would accumulate by the pipe that led to the outside, via the hole the pipe came from. He also confirmed that room was extremely cold as a result.

Interview and observation on 02/02/26 at 1:04 P.M. with Maintenance Technician #205 confirmed the temperature in Resident #1's bathroom was 77 degrees Fahrenheit (F); however, the temperature surrounding the pipe near the base of the toilet was 45°. He confirmed the temperature was more acceptable if the bathroom door was left open.

Review of the facility policy titled Resident Rights

Based on record review and interviews, the facility failed to ensure that residents receiving skilled nursing services had evaluations completed and documented by a nurse at least every seven days as required. This affected one resident (#11) of one resident reviewed for skilled services. The facility census was 33.

Findings include:

Record review revealed Resident #11 was receiving skilled care for wound care. The resident record lacked evidence of nursing evaluations being completed and documented every seven days as required.

Interview on 10/22/25 at 12:57 P.M. with the Health and Wellness Director confirmed weekly evaluations were not being completed on Resident #11. The Health and Wellness Director stated they received the form for weekly skilled evaluations from the Regional Manager but acknowledged that the process had not yet been implemented.

Based on observation, interview and record review, the facility failed to maintain the kitchen in a clean and sanitary condition and failed to ensure food service equipment was operating properly. This has the potential to affect all 33 residents residing in the facility.

Findings include:

Observation on 10/22/25 from 11:30 A.M. to 12:20 P.M of the kitchen revealed the kitchen hood contained visible grease and dust buildup. The kitchen hood sticker revealed the hoods were last cleaned in July of 2025. The floor in the food preparation area was visibly soiled with food debris and residue.

Interview with Cook #106 on 10/22/25 at 12:10 P.M. confirmed the kitchen hood was greasy with dust buildup and needed cleaning. Cook #106 also confirmed the floor was dirty and needed to be deep cleaned.

Record reviews revealed the dishwasher did not meet the required wash and rinse temperatures for breakfast, lunch and dinner on 10/03/25. Temperature on 10/03/25 for the dishwasher at breakfast time had a wash temperature of 140 degrees Fahrenheit (F) and a rinse temperature of 170 degrees F. The temperature on 10/03/25 for the dishwasher at lunch time had a wash time of 145 degrees F and a rinse temperature of 170 degrees F. The temperature on 10/03/25 for the dishwasher at dinner time had a rinse temperature of 178 degrees F.

Interview with Cook #1066 on 10/22/25 at 12:15 P.M. confirmed the dishwasher did not reach the required temperature on 10/03/25, and Executive Director was notified of the issue on that day.

Based on observation and interviews, the facility failed to ensure a safe environment in the residents' rooms. This affected one resident (#17) of three resident rooms reviewed for environment. The facility census was 33.

Findings include:

Observation on 10/22/25 at 9:20 A.M. in Resident #17's room revealed there was no lighting in the bathroom. The bathroom had two lights over the sink and one light in the ceiling.

Interview with Licensed Practical Nurse (LPN) #101 on 10/22/25 at 9:25 A.M. confirmed all three lights were burned out. LPN #101 confirmed the light switch controlled all three lights.

A second observation on 10/22/25 at 2:55 P.M. confirmed lighting in the bathroom was out in Resident #17's bathroom.

Interview on 10/22/25 at 2:55 P.M. with LPN #101 verified the lights in Resident #17's bathroom were still out. LPN #101 was going to notify the Execute Director immediately.

Based on the review of the medical record, review of the facility investigation, interview with the staff and review of the facility policy, the facility failed to protect Resident #28 from inappropriate staff behaviors. This affected one resident (Resident #28) of three reviewed for inappropriate behavior.

Findings included:

Review of the medical record revealed Resident #28 was admitted to the facility on 12/18/24. Diagnoses included cerebral infarction, acute kidney failure, diabetes, right sided hemiplegia, hypotension, hypothyroidism, dementia, chronic obstructive pulmonary disease, Alzheimer's disease, atrial fibrillation, insomnia, and gastric ulcer. He was discharged to another facility on 01/10/25.

Review of the Functional Assessment dated 12/18/24 revealed Resident #28 had impaired cognition and required assistance with all activities of daily living.

Review of the facility investigation dated 01/01/25 revealed Family Member (FM) #330 brought allegations of inappropriate behavior by the Director of Health and Wellness (DHW) toward her family member, Resident #28. She reported the incident to Licensed Practical Nurse (LPN) #112 who was on duty. LPN #112 notified the Executive Director (ED) via a telephone call at 11:28 A.M. LPN #112 told the ED that FM #330 was coming in the next day and she had a recording of the DHW saying she crawled into bed with Resident #28 and kissed him.

Review of the unsigned typed statement from FM #330 dated 01/01/25 at 11:38 A.M. revealed the ED called FM #330 to discuss the conversation that FM #330 had with LPN #112. FM #330 stated on 12/29/24 she came into the facility to visit Resident #28 and brought her son with her to witness any conversations. On 12/30/24 the family had come into the facility and gave a 30-day notice due to an application for Medicaid in July 2024 and the facility was aware that his discharge was going to happen. At that time, FM #330 stated the DHW had told her she crawled into bed with Resident #28 and kissed his face to wake him up. FM #330 then put an application (app) on her telephone to record the conversation without the staffs knowledge. On 12/31/24 when FM #330 came into the community to visit Resident #28, she activated her app and alleged the DHW stated that she kissed Resident #28 three times. FM #330 also stated she recorded Resident #28 stating that woman keeps kissing him. FM #330 stated she did not feel her family member was safe at the facility and the person she trusted the most, was violating him and she feared retaliation. She stated she thought DHW was sabotaging Resident #28's transfer to another facility. FM #330 asked that the DHW had a few days off so she was not at the facility to sabotage him being accepted by another facility.

Review of the unsigned typed statement from Business Office Manager (BOM) #117 dated 01/01/25 at 12:43 P.M. revealed she had been in and out of the office when FM #330 was in the office speaking to the DHW. She stated FM #330 was in the office with DHW for about 15 to 20 minutes and she did not hear the DHW say anything to FM #330 about crawling into bed and kissing Resident #28.

Review of the unsigned typed statement from DHW dated 01/01/25 at 3:59 P.M. revealed she had told FM #330 that she had sat on the side of Resident #28's bed on Monday (12/30/24) evening to give him his medication and she did kiss him goodnight on the forehead. She had worked the floor from 2:00 P.M. to 8:00 P.M. and she stated she did not crawl into his bed.

Further review of the facility investigation revealed on 01/04/25 at 9:00 A.M., FM #330 allowed the ED to listen to the recording of the DHW from 12/31/24. On the recording the DHW could be heard saying to FM #330 that Resident #28 let her kiss him three times and he did not mind. The ED also listened to the recording of Resident #28, from 01/01/25, when FM #330 had asked him if the woman who was always kissing him had been in to see him today and the resident stated she was always coming in to kiss him. FM #330 had told him the DHW should not be doing that because she was not his wife or girlfriend. The DHW was suspended from 01/01/25 to 01/07/25 due to inappropriate action of kissing Resident #28 on the forehead which resulted in making the family member uncomfortable.

On 01/17/25 at 9:00 AM an interview with the ED revealed the Specified Perpetrator was their Director of Health and Wellness. She stated she had been counseled and suspended during the investigation and they unsubstantiated the allegation. She stated the DHW liked to kiss residents on the forehead and she had been educated not to do that anymore. She stated she was not told by the family that the DHW kissed Resident #28 on the lips or got into bed with him. She stated they did not do a Self-Reported Incident either because they unsubstantiated the allegation. She stated another nurse (Nurse/BOM #117) was with the DHW when she spoke to the family and she denied hearing the DHW saying she kissed him or that she got into bed with him.

On 01/17/25 at 11:30 A.M. an interview with BOM #117 revealed she had been in and out of the office when the family of Resident #28 was in the office speaking to the DHW. She stated they were in the office for a long time, however she had to go in and out of the office because the copier was in that office. She stated she never heard any of the conversation. She stated she had never seen the DHW act inappropriately with a resident.

On 01/17/25 at 12:19 P.M. an interview with the DHW revealed she had been working the floor on 12/29/24 and she had gone in to give Resident #28 his medication. She stated she sat him up on the side of the bed, and she sat down on the bed beside him to give him his medication because it was safer and she was not bending over him to give them. She stated that the resident took the medication and asked what time it was and she stated 7:30 and Resident #28 had asked if it was in the morning and she stated to him that it was 7:30 P.M. She stated she asked him if he wanted to get up and go out to the lounge or lay back down in bed and he stated he wanted to stay in bed. She stated she kissed his forehead and laid him back down in the bed. She stated she never kissed him on the mouth and never laid down in bed with him. She stated she did tell FM #330 she kissed him on the forehead.

On 01/17/25 at 1:15 P.M. an interview with LPN #112 revealed she knew FM #330 previously and she came to her on 01/01/25 indicating she (FM #330) trusted her (LPN #112) and she was uncomfortable with the DHW kissing Resident #28. LPN #112 stated she told FM #330 that she had to report it to the ED. She stated she went immediately and did a head-to-toe assessment on Resident #28 with no concerns and then she called the ED to notify her of the situation. She stated she documented that assessment on 01/01/25.

On 01/17/25 at 1:20 P.M. a follow up interview with the ED verified she had heard the voice recording. She stated FM #330 could be heard asking the DHW how Resident #28 was doing and the DHW stated he was doing well and he let her kiss him three times. She stated then you could hear FM #330 prompting Resident #28 by asking him if he had seen the DHW, and he did not know who she was. FM #330 stated to the resident that it was the woman who was always kissing him, and the resident responded that she was always kissing him.

Review of the facility policy titled, Abuse, Neglect and Exploitation

Based on record review, interview and policy review, the facility failed to ensure Former specified resident (FSR) #28 was free from verbal abuse. This affected one of three residents reviewed for abuse and had the potential to affect all residents residing in the facility. The census was 27.

Findings include:

Record review revealed FSR #28 was admitted 04/13/24 with diagnoses of Alzheimer's disease, unspecified dementia, unspecified severity, with behavioral disturbances. FSR #28 had a severe cognitive impairment and was being provided end of life services from Hospice. Review of the physician orders revealed FSR #28 required a mechanical lift for all transfers and was prescribed the antipsychotic risperidone one milligram twice daily for dementia and alprozalam 0.25 mg every four hours as needed for agitation. Review of the Skin Observation dated 11/23/24 completed by Licensed practical nurse (LPN) #138 revealed a head-to-toe assessment was completed and noted reddened petechiae to FSR #28's face and top of head which was not unusual for him. No other redness was found, and skin was intact.

Review of investigation summary provided by the Executive Director (ED) revealed the Dining Services Coordinator (DSC) overheard a caregiver using expletives towards a resident. The DSC discovered the resident's door was locked when she attempted to enter. The DSC waited for the perpetrator to exit at which time the caregiver was confronted about the language used towards FSR #28. The DSC notified the ED immediately. Caregiver #140 was interviewed on 11/23/24 by the ED at which time she admitted to using profanity towards FSR #28.

Interview on 11/23/24 at 7:20 P.M. with Caregiver #139 revealed she was in the room and witnessed Caregiver #140 using profanity towards FSR #28 and did not report the incident. On 11/23/24 at 7:25 P.M. both caregivers were terminated.

Interview on 01/02/24 at 11:56 A.M. with LPN #138 confirmed she completed the head-to-toe assessment after verbal abuse had been identified and found FSR #28's skin was intact and absent of any bruising.

Interview on 01/02/24 with the ED revealed both caregivers had been employed less than 30 days and had not been employed long enough for an evaluation to have been completed. The ED revealed a pre-employment background check was completed and came back clear. All staff that worked the night of the incident were interviewed and it appeared the incident was isolated and staff denied having witnessed the caregivers being verbally or physically abusive to any of the residents.

Interview on 01/02/24 at 1:56 P.M. with Caregiver #139 confirmed she was the one that used profanity towards FSR #28, not Caregiver #140 as noted in the investigation summary. Caregiver #139 reported FSR #28 called her a racial slur to which she responded with expletives which was what the DSC overheard.

Interview on 01/02/24 at 1:56 P.M. with DSC revealed she overheard someone using expletives when speaking to a resident as she was enroute to the B hall. As she neared FSR #28's door she again overheard someone use expletives threatening to do harm to the resident. The DSC then tried to open FSR #28's door but it was locked so she stood outside the door and waited for the individual(s) to exit. Two female caregivers exited the room at which time the DSC confronted them about the language she overheard used towards the resident. The shorter of the two caregivers reported FSR #28 used profanity towards her first then stated, I was returning the same energy. After the confrontation with the caregivers, she went to her car and phoned the ED about what she overheard.

Review of the Abuse Policy last revised May 2021 revealed the DSC and ED took the outlined steps to protect the resident by removing the caregivers immediately, terminating their employment, having the resident examined by the nurse, and completing a thorough investigation.

Review of the Self Reported Incident #255011 dated 12/11/24 revealed the facility reported an incident of verbal abuse that occurred on 11/23/24 at 6:30 P.M. and substantiated verbal abuse occurred.

This violation represents non-compliance investigated under Complaint Number OH00160655.