The most recent inspection on file for Brookdale Findlay took place on October 7, 2025. Across the 4 inspections published by the Ohio Department of Health, surveyors cited 8 deficiencies.
A deficiency is a rule the surveyor found the facility was not meeting. Ohio inspects against two rule books at once, so most findings carry a federal code and an Ohio code for the same problem; each is counted once here, the way the state counts it. Correction dates are the state's confirmation that the issue was fixed.
This report reproduces what Ohio publishes and nothing else. Of the 4 inspections listed, the state publishes the surveyor's written findings for 3; for the other 1 it publishes only the date, the type of visit and the number of deficiencies - 1 of which found none.
Facility Details
Inspections
4 on file · 8 deficienciesOctober 7, 2025Licensure survey2 deficiencies▼
R-0140Background check required▼
Based on review personnel files and staff interview, the facility failed to ensure all staff were checked against the Ohio Nurse Aide Registry upon hire. This affected two (Executive Director (ED) and Licensed Practical Nurse (LPN) #124) of six employee files reviewed and had the potential to affect all 32 residents who reside in the facility. The facility census was 32.
Findings include:
Review of personnel file for ED revealed the staff member was hired 04/18/25. Further review of the ED's personnel file revealed no evidence that the employee was checked via the Ohio Nurse Aide Registry upon hire.
Review of personnel file for LPN #124 revealed the staff member was hired on 05/01/25. Further review of LPN #124's revealed no evidence that the employee was checked via the Ohio Nurse Aide Registry upon hire.
Interview on 10/07/25 at 11:56 A.M. with the Wellness Director confirmed the facility did not check all staff against the Ohio Nurse Aide Registry.
R-0559Procure, store, prepare, distribute and serve foods▼
Based on observations, staff interviews, and policy review, the facility failed to ensure dietary staff wore hairnets properly while in food service/preparation areas. The facility also failed to ensure food was stored and served in a safe and sanitary manner. This had the potential to affect all 32 residents who reside in the facility. The facility census was 32.
Findings include:
1. Observation on 10/07/25 at 9:18 A.M. of the kitchen revealed in the dry storage area there was one clear tub of croutons prepped on 07/04/25 with no use by date and lid not on tightly; one bag of noodles open with no date; and one bag of wheat pasta open with no date. In the reach in freezer one bag of green beans open with no date. In the reach in refrigerator one clear container of jello prepped on 10/03/25 with no use by date; one clear container of beets prepped on 09/19/25 with use by date of 09/26/25; one clear container of coleslaw prepped on 10/03/25 with no use by date; one container of cottage cheese with date on lid of 09/18 with no use by date; and one sleeve of boiled eggs open with no date.
Interview on 10/07/25 at 9:28 A.M. with Dining Service Coordinator (DSC) #106 verified the above findings. DSC #106 stated the 09/18 date on the cottage cheese was the day it came in. DSC #106 verified no open date or use by date were seen on the cottage cheese.
Review of policy titled Food Storage revised 06/24 revealed all foods must be stored in a manner that maximized nutrient retention, quality, and food safety. A first in first out (FIFO) rotation method should be used for storage purposed: all new products should be stored behind existing stock to ensure utilization of current stock first. It is recommended to use Use First stickers to help identify product.
2. Observation on 10/07/25 from 12:09 P.M. to 12:29 P.M. of meal service revealed DSC #106 only had hairnet covering her ponytail. Observations revealed the hair around DSC #106's face was uncovered. Also few loose hairs noted at the nape of the neck not covered by the hairnet and was serving food. Cook #110 was observed with gloved hands touching the hamburgers, buns, ketchup, mustard, and mayonnaise squeeze bottles, green beans, pickles, onions, lettuce, tomatoes, knife, cookies, and plates. Cook #110 was observed to get ketchup on glove and wipe the glove on his apron. Cook #110 then proceeded to touch the same products listed above to plate the meal for the residents. Cook #110 served all 21 residents in the dining room and four room trays with the same gloved hands. Cook #110 was also observed to remove an empty steam table pan and lid from the steam table and place on the counter with the same gloves.
Interview on 10/07/25 at 12:30 P.M. with Cook #110 verified he touched all the above items and wiped his hand on the apron and continued to wear the same gloves for all of it.
Interview on 10/07/25 at 12:32 P.M. with DSC #106 verified she had stragglers and her hairnet was only on her ponytail. DSC #106 stated no one had ever told her all her hair had to maintained when serving food.
Review of policy titled Hair Restraints revised 12/24 revealed all hair must be kept covered. Hair that cannot be covered with a single hairnet will wear two (one for the front and one for the back).
Review of policy titled Use of Gloves revised 08/24 revealed gloves should be changed and hands washed inn between tasks and after any interruption or potential contamination. Single use food handlers gloves should only be used for one task at a time such as working with ready-to-eat foods or with raw foods and discarded when damaged or soiled, or when interruption occur during use.
November 14, 2024Licensure survey4 deficiencies▼
R-0127Types of allowed personal care services training▼
Based on personnel file review and staff interview, the facility failed to ensure staff were trained by a registered nurse (RN) or licensed practical nurse (LPN) under the direction of an RN. This had the potential to affect all 28 residents in the facility. The census was 28. Findings include: Interview on 11/14/24 at 4:30 P.M. with the Executive Director (ED) and concurrent review of the personnel file for Caregiver #101 revealed a hire date of 07/29/24. Further interview and review of the document titled, Ohio Resident Aid TrainingBased on personnel file review and staff interview, the facility failed to ensure staff were trained by a registered nurse (RN) or licensed practical nurse (LPN) under the direction of an RN. This had the potential to affect all 28 residents in the facility. The census was 28.
Findings include:
Interview on 11/14/24 at 4:30 P.M. with the Executive Director (ED) and concurrent review of the personnel file for Caregiver #101 revealed a hire date of 07/29/24. Further interview and review of the document titled, Ohio Resident Aid Training
R-0313Annual health assessment content▼
Based on medical record review and staff interview, the facility failed to ensure residents were assessed to determine whether or not each resident was capable of self-administering medications. This affected two (#11 and #15) of five resident records reviewed. The facility census was 28.
Findings include:
1. Review of the medical record for Resident #11 revealed an admission date of 12/09/22 with diagnoses of hypertension and anxiety. Further review revealed no annual assessment for medication self-administration was completed for Resident #11 in 2023.
2. Review of the medical record for Resident #15 revealed an admission date of 11/15/21 with diagnoses of hypertension and edema. Further review revealed no annual assessment for medication self-administration was completed for Resident #15 in 2023.
Interview on 11/14/24 at 3:00 P.M. with the Health and Wellness Director confirmed no medication self-administration assessment was completed for Resident #11 and Resident #15 in 2023.
R-0339Administered meds - given only to and as prescribed▼
Based on observation, staff interview, medical record review, and review of the pharmacy packaging, the facility failed to ensure medications were administered per pharmacy guidelines. This affected one (#13) of two residents observed during medication administration. The facility census was 28.
Findings include:
Review of the medical record for Resident #13 revealed an admission date of 05/26/23 with diagnoses of hypertension and hypokalemia (low potassium).
Review of the physician order initiated 05/26/23 revealed Resident #13 received potassium chloride (CL) extended release (ER) 20 milliequivalents (mEq) with instructions to give one tablet by mouth once daily for hypokalemia.
Review of the pharmacy packaging label for Resident #13's medications revealed documentation on a dose of potassium CL ER tab 20 mEq for the medication not to be crushed.
Interview and observation on 11/14/24 beginning at 9:18 A.M. revealed Licensed Practical Nurse (LPN) #201 dispensed Resident #13's morning medications. LPN #201 mixed Resident #13's pills with applesauce. LPN #201 stated Resident #13 preferred her potassium pill crushed because it was a large pill. LPN #201 proceeded to crush the potassium pill and at 9:20 A.M. LPN #201 confirmed she mixed the crushed potassium pill into the applesauce with the other medication. Continued observation revealed LPN #201 administered the medications to Resident #13 while she sat in her recliner in her room. Resident #13 was observed to consume all medications.
Interview on 11/14/24 at 9:27 A.M. with LPN #201 and concurrent review of the pharmacy packaging label revealed the potassium pill should not have been crushed. LPN #201 confirmed she should have not crushed Resident #13's potassium pill.
R-0391Resident incidents and log; identify resident upon request▼
Based on resident record review, review of the facility's incident log, and staff interview, the facility failed to ensure the incident log included all incidents separate from the resident record. This affected one (#11) of one residents reviewed for falls. The facility census was 28.
Findings include:
Review of the medical record for Resident #11 revealed an admission date of 12/09/22 with diagnoses of hypertension and anxiety.
Review of a progress note dated 08/16/24 revealed Resident #11 fell in his room on 08/14/24.
Review of the facility's incident log for August 2024 revealed no evidence of Resident #11's fall which occurred on 08/14/24.
Interview on 11/14/24 at 2:35 P.M. with the Health and Wellness Director (HWD) confirmed Resident #11's unwitnessed fall on 08/14/24 was not documented on the incident log. Additionally, the HWD confirmed Resident #11's fall should have been included on the facility's incident log.
May 3, 2023Licensure survey2 deficiencies▼
R-0302Types of residents not allowed in RCFs▼
Based on medical record review, staff interview, and review of online resource per the National Pressure Injury Advisory Panel (NPIAP), the facility failed to provide the necessary care and treatment for a resident experiencing a rapid change of condition and a timely seek alternate placement when care could not be met at the facility. This affected one (#34) of two residents reviewed for skin breakdown. The census was 33.
Findings include:
Review of the medical record for Resident #34 revealed an admission date of 07/30/20, with diagnoses of hypothyroid, hypertension, atrial fibrillation, gout, hyperlipidemia, osteoarthritis, pain in shoulder, and anxiety. Resident #34 was sent to hospital on 12/21/22.
Review of the health reassessment for Resident #34 dated 11/18/22 revealed the resident was cognitively intact with no memory loss. Resident #34 needed assistance with the use of the bathroom, was unable to use the bathroom on his own. Resident #34 used incontinence products, brief for incontinence supplies. Resident #34 had fallen in the past twelve months and used a walker for mobility inside apartment and a motorized wheelchair for mobility when out of apartment.
Review of a provider order dated 12/02/22 revealed an order to increase Calmoseptine Ointment to three times a day (TID) to buttock/open area until healed.
Review of nursing progress note dated 12/03/22 at 11:21 P.M., revealed after the resident sat on toilet, sanguineous fluid discharged from right buttock. This nurse held pressure applied telfa, abdominal pad and secured with paper tape. Extra pad applied to brief. This nurse notified the Certified Nurse Practitioner (CNP) and asked for any other instructions. No new orders will continue to be monitored. Daughter notified.
Review of nursing progress note dated 12/05/22 at 9:59 A.M., revealed dressing changed to bottom due to incontinence. Open area on left buttocks measures 2 centimeters (cm) by (x) 1 cm and draining sanguineous fluid. Open area right buttock pencil point size cleaned with saline wash and cushioned dressing applied.
Review of the facility form titled Open Area Flow Sheet dated 12/05/22, documented a pressure wound on left buttock, measuring 2 cm x 1 cm, small amount of serosanguineous red odorless drainage, 100% wound bed Clean and pink, with surrounding tissue blanchable. The primary wound care provider: health care provider and current treatment: Triad 1 time every other day. Right buttock (no wound type indicated) measured 1 millimeter (mm) x 1 mm, no drainage, with surrounding tissue blanchable. The primary wound care provider: healthcare provider and current treatment: Triad 1 time every other day.
Review of a nursing progress notes dated 12/15/22 at 7:05 P.M., revealed the Resident Care Assistant (RCA) reported the resident is sitting on his chair waiting for a new dressing. Large area to right buttocks dark purple/blackish, scant amount of sanguineous drainage, skin pealed to area. This nurse applied non-stick dressing with gauze for padding. Note left for PA to assess wounds tomorrow. Daughter notified by this nurse.
Review of the provider order sheet for Resident #34 dated 12/16/22, revealed an order to refer to local wound clinic for skin breakdown on bottom as soon as possible. Triad paste to wound one time every 2 days. Encourage resident to change positions every two hours, and a ROHO cushion for positioning.
Review of the provider progress note dated 12/16/22 documented a 11 cm x 4-1/2 cm black area, nontender to palpation lesion on the lateral medial aspect of the right buttocks. It is not soft but hard to palpate.
Review of nursing progress note dated 12/17/22 revealed Triad wound dressing pasted not available has not arrived from pharmacy.
Review of the facility form titled Open Area Flow Sheet dated 12/18/22 revealed a suspected deep tissue injury with measurements of 12 cm x 20 cm, moderate amount of sanguineous red drainage with no odor, the surrounding tissue red with indications of pain, unable to visualize the wound bed and experiencing pain.
Review of nursing progress notes of dated 12/18/22 at 11:46 P.M., revealed both buttock areas were cleansed with sterile saline spray wash and an allevyn pad was placed on each buttock.
Review of nursing progress note dated 12/19/22 revealed Triad wound dressing paste not available has not arrived from pharmacy. Wound clinic appointment scheduled for 12/20/22. Talked to daughter related to wound and hospice or skilled nursing facility.
Review of wound clinic note dated 12/20/22 revealed coccyx area measured 14 cm x 11.5 cm x 0.2 cm- pressure -induced deep tissue damage of sacral region, antibiotics ordered, laboratory test, x-ray and air mattress, Meligisorb AG pad twice a day.
Review of nursing progress note dated 12/21/22 revealed resident sent to emergency room for possible sepsis from stage 2/3 decubitus ulcer, mild surrounding erythema and serosanguineous drainage. Wound is foul-smelling and necrotic tissue present.
Interview on 05/03/23 at 4:50 P.M., with Director of Nursing #25 verified the skin assessments were missing information and incomplete, there is no evidence of the Triad wound treatment being applied from 12/05/22 to 12/21/22, no actual order for the Triad wound treatment until 12/16/22, no orders for the dressing being applied as documented in progress notes, a referral for skilled placement was not sent until 12/20/22, that Resident #34 was not receiving skilled services or hospice care at that time, on 12/21/22 Resident #34 was sent to emergency department for change in condition related to wound progression and never returned to facility.
Review of online resource per the NPIAP titled Pressure Injury Stages at https://npiap.com/page/PressureInjuryStages revealed a pressure injury was defined as localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury could present as intact skin or an open ulcer and might be painful. The injury occurred because of intense and/or prolonged pressure or pressure in combination with shear. An unstageable pressure injury was defined as skin and tissue loss in which the extent of tissue damage within the ulcer could be confirmed because it was obscured by slough or eschar. If slough or eschar were removed, a Stage 3 or Stage 4 pressure injury would be revealed.
This violation represents non-compliance investigated under Complaint Number OH00142191
R-0350Requirements for applications of dressings▼
Based on medical record review and staff interview, the facility failed to obtain a physician's order for the application of dressings. This affected one (#34) of two residents reviewed for skin breakdown. The census was 33.
Findings include:
Review of the medical record for Resident #34 revealed an admission date of 07/30/20, with diagnoses of hypothyroid, hypertension, atrial fibrillation, gout, hyperlipidemia, osteoarthritis, pain in shoulder, and anxiety. Resident #34 was sent to hospital on 12/21/22.
Review of the health reassessment for Resident #34 dated 11/18/22 revealed the resident was cognitively intact with no memory loss. Resident #34 needed assistance with the use of the bathroom, was unable to use the bathroom on his own. Resident #34 used incontinence products, brief for incontinence supplies. Resident #34 had fallen in the past twelve months and used a walker for mobility inside apartment and a motorized wheelchair for mobility when out of apartment.
Review of the medical record for Resident #34 revealed an admission date of 07/30/20, with diagnoses of hypothyroid, hypertension, atrial fibrillation, gout, hyperlipidemia, osteoarthritis, pain in shoulder, and anxiety. Resident #34 was sent to hospital on 12/21/22.
Review of the health reassessment for Resident #34 dated 11/18/22 revealed the resident was cognitively intact with no memory loss. Resident #34 needed assistance with the use of the bathroom, was unable to use the bathroom on his own. Resident #34 used incontinence products, brief for incontinence supplies. Resident #34 had fallen in the past twelve months and used a walker for mobility inside apartment and a motorized wheelchair for mobility when out of apartment.
Review of nursing progress note dated 12/03/22 at 11:21 P.M., revealed after the resident sat on toilet, sanguineous fluid discharged from right buttock. This nurse held pressure applied telfa, abdominal pad and secured with paper tape. Extra pad applied to brief. This nurse notified the Certified Nurse Practitioner (CNP) and asked for any other instructions. No new orders will continue to be monitored. Review of the medication administration record (MAR), treatment administration record (TAR) and physician orders revealed no evidence of an order or documentation indicating orders for the dressings that were applied to right buttocks.
Review of nursing progress note dated 12/05/22 at 9:59 A.M., revealed dressing changed to bottom due to incontinence. Open area on left buttocks measures 2 centimeters (cm) by (x) 1 cm and draining sanguineous fluid. Open area right buttock pencil point size cleaned with saline wash and cushioned dressing applied. Review of the MAR, TAR and physician orders revealed no evidence of an order or documentation indicating orders for the dressings that were applied to left and right buttocks.
Review of the facility form titled Open Area Flow Sheet dated 12/05/22, documented a pressure wound on left buttock, measuring 2 cm x 1 cm, small amount of serosanguineous red odorless drainage, 100% wound bed Clean and pink, with surrounding tissue blanchable. The primary wound care provider: health care provider and current treatment: Triad 1 time every other day. Right buttock (no wound type indicated) measured 1 millimeter (mm) x 1 mm, no drainage, with surrounding tissue blanchable. The primary wound care provider: healthcare provider and current treatment: Triad 1 time every other day. Review of the MAR, TAR and physician orders revealed no evidence of an order or documentation indicating orders for the Triad treatment.
Review of a nursing progress notes dated 12/15/22 at 7:05 P.M., revealed the Resident Care Assistant (RCA) reported the resident is sitting on his chair waiting for a new dressing. Large area to right buttocks dark purple/blackish, scant amount of sanguineous drainage, skin pealed to area. This nurse applied non-stick dressing with gauze for padding. Note left for PA to assess wounds tomorrow. Review of the MAR, TAR and physician orders revealed no evidence of an order or documentation indicating orders for the dressings that were applied.
Review of the provider order sheet for Resident #34 dated 12/16/22, revealed an order to refer to local wound clinic for skin breakdown on bottom as soon as possible. Triad paste to wound one time every 2 days. Encourage resident to change positions every two hours, and a ROHO cushion for positioning.
Review of the provider progress note dated 12/16/22 documented a 11 cm x 4-1/2 cm black area, nontender to palpation lesion on the lateral medial aspect of the right buttocks. It is not soft but hard to palpate.
Review of nursing progress note dated 12/17/22 revealed Triad wound dressing pasted not available has not arrived from pharmacy.
Review of the facility form titled Open Area Flow Sheet dated 12/18/22 revealed a suspected deep tissue injury with measurements of 12 cm x 20 cm, moderate amount of sanguineous red drainage with no odor, the surrounding tissue red with indications of pain, unable to visualize the wound bed and experiencing pain.
Review of nursing progress notes dated 12/18/22 at 11:46 P.M., revealed both buttock areas were cleansed with sterile saline spray wash and an allevyn pad was placed on each buttock. Review of the MAR, TAR and physician orders revealed no evidence of an order or documentation indicating orders for the dressings that were applied to left and right buttocks.
Review of nursing progress note dated 12/19/22 revealed Triad wound dressing paste not available has not arrived from pharmacy. Wound clinic appointment scheduled for 12/20/22. Talked to daughter related to wound and hospice or skilled nursing facility.
Review of wound clinic note dated 12/20/22 revealed coccyx area measured 14 cm x 11.5 cm x 0.2 cm- pressure -induced deep tissue damage of sacral region, antibiotics ordered, laboratory test, x-ray and air mattress, Meligisorb AG pad twice a day.
Review of nursing progress note dated 12/21/22 revealed resident sent to emergency room for possible sepsis from stage 2/3 decubitus ulcer, mild surrounding erythema and serosanguineous drainage. Wound is foul-smelling and necrotic tissue present.
Interview on 05/03/23 at 4:50 P.M., with Director of Nursing #25 verified there is no evidence of the Triad wound treatment being applied from 12/05/22 to 12/21/22, no documentation on the MAR and TARs, no actual order for the Triad wound treatment until 12/16/22, no orders for the dressing being applied as documented in progress notes, and Resident #34 was not receiving skilled services or hospice care at that time.