Brookdale Mentor

Based on observation and interview, the facility failed to store garbage in a proper refuse receptacle. This had the potential to affect all 47 residents residing in the facility.

Findings include:

Observation on 10/16/25 at 11:52 A.M. with Dietary Manager (DM) #600 of the outside dumpster and surrounding area revealed garbage was on the ground surrounding the dumpster area which included plastic cups, plastic silverware, used wrappers, papers, and multiple clear filled garbage bags and a large black filled garbage bag sitting next to the dumpster which was halfway filled. Interview at the time of the observation with DM #600 verified the above findings, and stated, yes it is bad out here. I know garbage everywhere.

Interview on 10/20/25 at 9:59 A.M. with Administrator revealed the facility had no policy regarding proper garbage disposal.

Based on observation, interview and facility policy review, the facility failed to maintain its grounds in a clean and safe manner by properly disposing of cigarette butts. This had the potential to affect all 47 residents residing in the facility. Findings include: Observation on 10/16/25 at 11:48 A.M. with Dietary Manager (DM) #600 revealed the employee designated smoking area was a grass area across from the outside dumpster. On the ground located in the grass area was about 100 cigarette butts approximately 20 feet from the facility. An empty black fireproof cigarette butt receptacle was located next to a bucket which was turned upside down. Upon walking on the sidewalk from the designated employee smoking area towards the building, there were multiple cigarette butts on the ground in the stones and mulch which was up against the building. Interview at the time of the observation with DM #600 verified there were approximately 100 cigarette butts on the grass and stated the employees sit on the turned over bucket but do not put the cigarette butts into the black fireproof receptacle but instead place the butts onto the ground. She confirmed the black receptacle was empty, and there were multiple cigarette butts in the mulch and stone next to the facility. When asked about how many cigarette butts appeared to be inside the mulch and stone area, she replied, over 50 cigarette butts. DM #600 verified the above observation was a fire hazard. Interview on 10/20/25 at 9:59 A.M. with the Administrator revealed the facility had no policy regarding maintaining the facility in a clean and safe manner including the proper disposal of cigarette butts. She indicated the facility only had a policy for evaluating residents to safely smoke, but it did not include disposal of cigarette butts. Observation on 10/20/25 at 11:19 A.M. with DM #600 revealed nine cigarette butts on the ground in the stones underneath and surrounding an outside propane gas grill which was located approximately ten feet away from the facility. Interview at the time of the observation with DM #600 verified the nine cigarette butts on the ground underneath and surrounding the outside propane gas grill. Review of the facility policy titled, Smoking EvaluationBased on observation, interview and facility policy review, the facility failed to maintain its grounds in a clean and safe manner by properly disposing of cigarette butts. This had the potential to affect all 47 residents residing in the facility.

Findings include:

Observation on 10/16/25 at 11:48 A.M. with Dietary Manager (DM) #600 revealed the employee designated smoking area was a grass area across from the outside dumpster. On the ground located in the grass area was about 100 cigarette butts approximately 20 feet from the facility. An empty black fireproof cigarette butt receptacle was located next to a bucket which was turned upside down. Upon walking on the sidewalk from the designated employee smoking area towards the building, there were multiple cigarette butts on the ground in the stones and mulch which was up against the building. Interview at the time of the observation with DM #600 verified there were approximately 100 cigarette butts on the grass and stated the employees sit on the turned over bucket but do not put the cigarette butts into the black fireproof receptacle but instead place the butts onto the ground. She confirmed the black receptacle was empty, and there were multiple cigarette butts in the mulch and stone next to the facility. When asked about how many cigarette butts appeared to be inside the mulch and stone area, she replied, over 50 cigarette butts. DM #600 verified the above observation was a fire hazard.

Interview on 10/20/25 at 9:59 A.M. with the Administrator revealed the facility had no policy regarding maintaining the facility in a clean and safe manner including the proper disposal of cigarette butts. She indicated the facility only had a policy for evaluating residents to safely smoke, but it did not include disposal of cigarette butts.

Observation on 10/20/25 at 11:19 A.M. with DM #600 revealed nine cigarette butts on the ground in the stones underneath and surrounding an outside propane gas grill which was located approximately ten feet away from the facility. Interview at the time of the observation with DM #600 verified the nine cigarette butts on the ground underneath and surrounding the outside propane gas grill.

Review of the facility policy titled, Smoking Evaluation

Based on medical record review, staff interview, resident interview, facility resident council minutes, facility staffing schedule, and facility call light report review, the facility failed to schedule enough staff to meet the needs of all residents. This had the potential to affect 53 of 53 residents in the facility.

Findings Include:

Review of resident medical records, and confirmed by Executive Director #101 on 03/28/25, revealed 16 residents (Residents #2, #3, #4, #6, #12, #15, #17, #21, #22, #29, #30, #31, #38, #48, #49, and #52) of the 53 in the facility needed physical assistance with transfers and other activities of daily living (ADLs) in the facility.

Interview with Caregiver #103 and Nurse #104 on 03/28/25 at 2:00 P.M. and 2:10 P.M. confirmed they do not have enough aides in the facility to meet the needs of the residents. Both staff stated the nurses will have to help the aides with answering call lights, especially ones that have been on for 15 minutes or more. They have been instructed to answer call lights within 10 to 15 minutes, and they confirmed that is not always possible because of the needs of the residents. They confirmed during day shifts, there should be no less than four aides, which would include two in the memory care unit, one for the rest of the first floor, and one for the second floor. They confirmed the schedule may reflect this happens, but the actuality is they do not have that many aides in the facility. Overall, they do not believe they have enough aides in the building on a routine basis to meet the needs of the residents.

Interview with Residents #18, #28, and #46 on 03/28/25 at 3:30 P.M., 3:40 P.M., and 4:10 P.M. confirmed they do not have enough aides in the facility for a vast majority of the time. When they push their call pendant, it will take more than 15 minutes for the aides to get to them. They confirmed it has not caused a health decline related to the time it takes them to answer the call pendants, but if they have to something they need help with, the aides do not get to them timely. Resident #18 stated she has waited up to an hour for her call pendant to be answered.

Interview with Executive Director #101 on 03/28/25 at 4:50 P.M. confirmed a full staffing schedule for the first and second shift (day/evening) is four aides, and for the third/night shift is two aides. For nursing, there should be two nurses for the first (day/evening) shift, and one nurse for the night shift. She confirmed during the week of 02/01/25 to 02/07/25, which was the staff schedule dates that was reviewed during this survey, she confirmed there were multiple days in which the facility did not meet these staffing numbers.

Review of facility Resident Council Minutes, dated 03/12/25, revealed the residents stated, nursing always are all very kind, but sometimes are hard to find when needed.

Review of facility Nursing Staffing schedule, dated 02/01/25 to 02/07/25, revealed the following confirmed information: On 02/03/25, there was only one aide working during first/day shift. On 02/04/25, there were only two confirmed caregivers/aides working during the first/day shift. On 02/05/25, there were two aides/caregivers that worked the full first/day shift and nurse who assisted as a caregiver from 11:00 A.M. to 2:30 P.M., and there were two aides/caregivers who worked second/evening shift, with one aide working from 2:00 P.M. to 6:00 P.M. On 02/07/25, there was only three aides/caregivers working on first shift and three aides/caregivers working on second shift. Based on information provided by Executive Director #101, there should have been four aides working on the first/day shift and second/evening shift.

Review of facility Call Light logs, dated 02/24/25 to 03/21/25, revealed a total of 183 call lights that took longer than 15 minutes to respond to. The longest call light response time documented was one hour and 48 minutes.

This violation represents non-compliance investigated under complaint number OH00162293.

Based on medical record review, staff interview, and facility policy review, the facility to provide adequate care and oversight to prevent a resident fall. This affected one (Resident #30) of three residents reviewed for falls. The census was 53.

Findings Include:

Resident #30 was admitted to the facility on 11/09/19. Her diagnoses were hypothyroidism, displaced commuted fracture of shaft of right fibula, hypotension, Parkinson's disease, cerebral palsy, and mild cognitive impairment. Review of her assisted living assessment, dated 12/10/24, revealed she had a mild cognitive impairment.

Review of Resident #30's bathing assistance service plan, dated 2023, revealed she needed physical assistance to go to the bathroom. One of her interventions included staff are to visit and offer to take her to the bathroom every two hours.

Review of Resident #30's tracking and monitoring documentation, dated 02/24/25 to 03/28/25, revealed no evidence to support the facility had visited and offered to take Resident #30 to the bathroom.

Review of Resident #30's fall investigations and progress note documentation, dated 02/24/25 to 03/21/25, revealed she fell seven times in this period. Each time, she was attempting to transfer/ambulate independently without asking for assistance. Specifically, on 03/21/25, she fell while she was attempting to go to the bathroom. There was no documentation to support the last time staff was in her room and visited/offered to assist her to the bathroom as her bathroom assistance care plan stated it would.

Interview with Health and Wellness Director (HWD) #102 on 03/28/25 at 4:50 P.M. confirmed they do not have ordered or guidelines that they check on any resident every two hours. They will typically check on all residents every four to six hours. When providing her the evidence that Resident #30 had a care plan intervention for staff to visit and offer to assist Resident #30 to the bathroom every two hours, she confirmed she was not aware that was an intervention and they had no evidence to support this was occurring.

Interview with Executive Director #101 on 03/28/25 at 4:50 P.M. also confirmed the facility (to her knowledge) does not have the capabilities to document they check on a resident every two hours. She was not aware Resident #30 had a care plan intervention to be visited and offer to assist to the bathroom every two hours.

Review of facility Falls Management policy, dated January 2025, revealed the facility will complete a fall risk evaluation at the time of move in/admission or per state regulations. A witnessed or reported unwitnessed fall, with out without injury, is reported to the facility incident reporting system. Residents who sustain a fall should have a post fall evaluation completed to consider possible interventions to reduce the potential for future falls and injury. Resident falls are noted in the resident record and entered into the incident reporting system. A post fall evaluation is completed after a resident fall, individualized interventions are considered, and the evaluation is a part of the resident record. Document the resident fall/injury, resident response, and interventions taken in the electronic medical record. Service plan is reviewed for potential fall interventions and updated as necessary. Review the fall at the next stand up meetings. Discuss resident fall(s) at the next collaborative care review meeting. Falls are tracked and trended as a clinical indicator for quality improvement opportunities.

The following violation was issued relative to incidental findings that were discovered during this complaint investigation completed on 03/28/25.

Based on observation, staff and resident interview, medical record review, review of the call light response time log and facility policy, the facility failed to ensure there was sufficient staff to timely address resident call lights. This affected two residents (#37 and #53) out of three residents reviewed for call lights and had the potential to affect all residents in the facility. The facility census was 59.

Findings include:

1. Interview on 10/11/24 at 8:30 A.M. with Resident #53 who was alert and oriented to person, place, and time revealed the staff response time when she activated her call pendant was too long. With the surveyor still in the room, the call pendent was activated at 8:33 A.M. and upon leaving the resident's room at 8:43 A.M. there were no staff approaching the resident's room and no staff response to the call. At 8:51 A.M. there was still no staff response to the call light upon surveyor returning to the resident's room at that time. Resident #53 stated no one had come to check on her.

Review of the facility call light response log for Resident #53's room dated 10/11/24 showed the call light was activated at 8:33 A.M. and was answered at 25 minutes and three seconds after activation.

An interview on 10/11/24 at 10:32 A.M. with Caregiver #127 revealed she tried to answer call lights timely but was not always able to when assisting others and at times the nurses would help answer call lights but not always. Caregiver #127 confirmed all caregivers were supposed to carry a walkie talkie (portable communication device that received activated call light signals) for call light assistance, but stated the nurses don't carry walkie talkies.

2. Review of Resident #37's medical record revealed an admission date of 04/20/2021. Diagnoses included systolic congestive heart failure, cognitive communication deficit, fracture of right femur, muscle weakness, and occlusion and stenosis of bilateral carotid arteries.

Observation on 10/11/24 at 10:40 A.M. to 10:54 A.M. of Resident #37 in the resident's room revealed the call light was activated while speaking with the resident. No care staff came to the room to answer the call light during this time . Further observation revealed no caregivers were in the hallway or at the nurses' station located near the resident room. At 10:45 A.M. Housekeeper #163 was seen in the hallway and interviewed. Housekeeper #163 revealed it took

a long time for residents to get help especially upstairs so she tried to assist where she could but was limited as to what she can do. Housekeeper #163 verified staff were nowhere to be found and said the facility can't keep workers and she feels bad for residents.

Interview on 10/11/24 at 10:54 A.M. with Caregiver #119 regarding the call light activation for Resident #37 revealed she was unaware of the call light being activated and then proceeded to turn on the walkie talkie that was observed in her hand. It was then heard over the walkie talkie that Resident #37 has the call light activated 14 minutes, who will respond. Caregiver #119 verified she should not have had the walkie talkie turned off because that was how she would know if a resident had activated their call light for help.

Interview on 10/11/24 at 10:55 AM with Programs Coordinator (PC) #146 revealed that staff performs two-hour rounds with frequent walk arounds as the practice used by staff for resident observation and was unsure where to obtain a walkie talkie. When asked about residents pulling their pullcords in between the two hours round for assistance PC #146 couldn't answer how the resident's needs would be met if, for example, they rounded 30 minutes prior to the pullcord being activated.

Review of the Resident Call System and Door Alarm Response Policy, date revised 05/2023, revealed associates should respond to resident call system alerts and door alarms in a reasonable and timely manner. Associates should ask for assistance if they cannot respond timely.

This violation represents non-compliance as an incidental finding investigated under Complaint Number OH00158175.

Based on observation, medical record review, review of the call light response time log, review of hospital documentation, review of facility policy and interviews, the facility failed to ensure Resident #50 was provided timely and adequate supervision, care and services to prevent a fall with major injury and to mitigate risk of future falls.

Actual harm occurred on 09/22/24 when Resident #50 sustained a fall with fracture when staff failed to respond timely to the resident's request for assistance. On 09/22/24 at 7:26 P.M. the resident activated her call light; however, staff did not address her call light and care needs for 43 minutes and 34 seconds during which time the fall occurred. Resident #50 was subsequently transferred to the hospital and diagnosed with a right femoral intertrochanteric fracture (that resulted from the fall at the facility). The resident required surgical intervention and remained hospitalized until 10/03/24 at which time she returned to the facility.

This affected one resident (#50) of four residents reviewed for falls. The facility census was 59.

Findings include:

Record review revealed Resident #50 was admitted to the facility on 12/02/21 with diagnoses including hypertension, edema, age related osteoporosis, and type two diabetes mellitus.

Review of the service plan for Resident #50, initiated on 12/02/21 and revised on 08/03/23, revealed the resident was at risk for falls. Interventions included bed to be in lowest position when resident in bed and encourage use of hip protectors to reduce risk of injury especially due to osteoporosis. On 06/24/24 additional interventions were added to include fall risk standard precautions, help with incontinence care due to uncontained bladder, assist with all activities of daily living and for staff to increase safety monitoring (no frequency/time frame for monitoring specified).

Review of the facility fall incident log dated 08/21/24 to 10/01/24 revealed Resident #50 had an unwitnessed fall in her room with injury on 09/22/24 at 7:50 P.M. and was sent to the emergency room (ER) for treatment.

Review of the medical record revealed a progress note dated 09/22/24 at 10:50 P.M. for Resident #50 stating she was observed at 7:50 P.M. by Licensed Practical Nurse (LPN) # 104 on the floor near her bed and was complaining of pain in her left arm and pain in her right leg. Resident #50's blood pressure was taken on the left arm in lying position at 162/91, heart rate 73, and respirations of 17. The note included no physical signs of head injury were noted during the unwitnessed fall; however, it was documented Resident #50 had signs of bruising to the back left arm but was unable to determine if it was normal (pre-fall) baseline. The on-call provider was contacted and Resident #50's contact was contacted regarding the fall. There was no documented evidence provided to support the bed was in low position or hipsters were on the resident at the time of the fall. Further review of the medical record revealed no evidence of a post-fall investigation to determine root cause and/or implement new interventions to prevent additional falls.

Review of a call light response time document provided by the facility, dated 09/22/24, revealed Resident #50 called for staff assistance at 7:26 P.M., the call light was acknowledged on the physical walkie talkie ( a portable communication device) system by staff at 17 minutes 12 seconds post-activation, but staff did not go in to assist Resident #50 for 43 minutes 34 seconds after the call light activation.

Review of local hospital records dated 09/22/24 revealed Resident #50 was brought to the emergency room (ER) after a mechanical fall at the facility. Resident #50 was diagnosed with a right femoral intertrochanteric fracture and had surgical repair on 09/24/24. Resident #50 was discharged back to the facility on 10/03/24.

An observation on 10/11/24 at 10:26 A.M. of Resident #50 revealed she was in her bed attempting to self-reposition. She was alert but disoriented to person, place and time, and unable to answer any questions. The resident's call pendant was observed tangled behind her neck and the bed was not in low position but instead was above knee height. When the resident was asked by the surveyor if she could reach the call pendant and press the button for help, Resident #50 was able to grab her call light to activate it, and the alert was heard from an echoing walkie talkie in the hallway. Caregiver #127 entered the room at 10:29 A.M. to answer the call and verified Resident #50's bed was not low enough to be considered low position. Resident #50 was wearing hip protectors at the time of the observation.

An interview on 10/11/24 at 10:32 AM with Caregiver #127 revealed she tried to answer call lights timely but was not always able to when assisting others and at times the nurses would help answer call lights but not always. Caregiver #127 confirmed all caregivers were supposed to carry a walkie talkie for call light assistance, but stated the nurses don't carry walkie talkies.

An interview on 10/11/24 at 12:15 P.M. with Executive Director (ED) #139 and Care Manager (CM) #164 regarding the call light response time log and post-fall documentation verified (by ED #139) that Resident #50's call light was activated at 7:26 P.M. on 09/22/24, was acknowledged by staff on the walkie talkie system within 17 minutes 12 seconds, but was not physically responded to and turned off/reset by staff for 43 minutes and 34 seconds which left Resident #50 waiting for care and services for that amount of time on the night of her fall. CM #164 verified there was no incident report generated for Resident #50's fall beside what was documented on the fall incident log on 09/22/24 and CM #164 verified there was no evidence of an investigation done post fall (to determine a root cause and/or to implement necessary interventions to prevent additional falls). CM #164 stated there should have been more follow up details documented on the fall for Resident #50.

An interview on 10/11/24 at 3:07 P.M. with Caregiver #131 revealed the caregiver worked the 2:00 P.M. to 10:00 P.M. shift on 09/22/24. Caregiver #131 stated Resident #50 requested a bed bath which Caregiver #131 completed and then Resident #50 was tucked into bed. Caregiver #131 left to shower another resident. While showering the next resident, the caregiver revealed Resident #50's call light was ringing but Caregiver #131 was in the middle of another resident's shower so she thought someone else would answer the call light for Resident #50. Once she completed the other resident's shower, Licensed Practical Nurse (LPN) #104 notified her of Resident #50 being on the floor. Caregiver #131 did not specify exact time frames of these details. There was no evidence provided to support the bed was in low position or hipsters were on the resident at the time of the fall.

An interview on 10/11/24 at 4:10 P.M. with LPN #104 revealed she worked on 09/22/24. She stated she was in the medication room when she received a call from Resident #50's daughter stating she was viewing the camera in her mother's room and observed Resident #50 on the floor. LPN #104 stated she went to the room of Resident #50 and observed Resident #50's right arm wedged in between the bed and the bed railing. Unsure of what to do she went and got the help of a caregiver and another nurse. Emergency Medical Services (EMS) were called, and the physician and daughter were notified of Resident #50 being transported to the hospital after the fall.

An interview on 10/17/24 at 10:39 A.M. with Resident #50's daughter revealed she had attempted to call Resident #50 on the phone the evening of 09/22/24 but her mom did not answer so she went to the camera that was recording in her mom's room and that was when she saw her mom on the floor yelling out for help. The daughter stated she then contacted the nurse's station at the facility via phone and it was a half hour before she could get a hold of anyone to go help her mom. The daughter stated she had not submitted this video footage to the facility. The video was also not provided to the state agency as part of the investigation.

Review of the Falls Management Policy, date revised 01/2024, revealed residents had the potential to fall and therefore the facility identified universal fall precautions. A witnessed or unwitnessed fall, with or without injury, would be reported in the incident reporting system. Residents who sustain a fall should have a post-fall evaluation completed to consider possible interventions to reduce potential of future falls and injury. Resident falls and post-fall evaluations should be noted in the resident record and recorded in the incident reporting system. When a fall occurs, the facility should document in the progress notes the residents fall/injuries, the resident response and interventions taken. Significant change of condition charting to be completed in the medical record. The service plan should be reviewed and updated with interventions as necessary. There were no details in the policy regarding what universal fall precautions consisted of for resident safety.

Review of the Resident Call System and Door Alarm Response Policy, date revised 05/2023, revealed associates should respond to resident call system alerts and door alarms in a reasonable and timely manner. Associates should ask for assistance if they cannot respond timely.

This violation represents non-compliance investigated under Complaint Number OH00158175.