Brookdale Lakeview Crossing

Based on resident and staff interviews, observation, and policy review, the facility failed to ensure food served was at an appropriate temperature. This affected three (Residents #68, #73 and #67) of 17 residents residing in the memory care. The facility census was 73.

Findings include:

Observation of lunch service on 02/03/26 at 12:05 P.M. revealed Dietary Aide #201 preparing plates for memory care. Seventeen plates were sitting on the top shelf of the prep station under a heat lamp. Dietary Aide #201 said there were no warm plates, heated covers, or heated carts to keep food hot. The only method used was an overhead heat lamp, where plates were stacked on top of each other.

Observation on 02/03/26 at 12:12 P.M. of food temperatures on steam table with Dining Manager #200 revealed carrots at 160 degrees Fahrenheit (F), rice at 163 degrees F and meatloaf at 169 degrees F.

Observation of the cart arriving in memory care on 02/03/26 at 12:20 P.M. revealed the last plate was served at 12:27 P.M.

Observation and interview on 02/03/26 at 12:27 P.M. with Dining Manager (DM) #200 revealed the test plate was removed from the cart and tasted. The carrots, meatloaf, and rice had good flavor, but the food was not hot enough to be appetizing and was described as lukewarm. DM #200 said no warming measures were used, such as a warming box, heated plates, or covers. DM #200 agreed food lost a lot of heat during the 22 minutes from plating to delivery and was not appetizing. DM #200 reported a warming box may be necessary to maintain temperatures.

Interview on 02/03/26 at 12:46 P.M. with Resident #73 stated the food tasted good, but it was not warm and often needs to be reheated.

Interview on 02/03/26 at 12:50 P.M. with Resident #68 stated lunch was not warm and was usually served cold.

Interview on 02/03/26 at 12:52 P.M. with Resident #67 stated lunch was lukewarm and they often ask staff to heat it up.

Interview on 02/03/26 at 12:59 P.M. with Caregivers #132 and #146 said residents often ask for food to be reheated, especially Residents #67 and #68. Both caregivers denied heating up any of the residents food during lunch service.

Review of the facility's food transport policy dated 05/21/20 revealed hot food must be kept at 140 degrees F or higher and cold food at 41 degrees F or lower. Food temperatures must be checked and recorded before service and after transport.

This violation represents non-compliance investigated under Complaint Number OH00169616.

This violation is an example of continued non-compliance from the survey dated 11/13/25.

Based on record review and staff interview, the facility failed to provide evidence that the personal care and techniques for unlicensed Care Partner #327 were verified by a licensed nurse prior to working unsupervised. This had the potential to affect all residents residing in the facility. The facility census was 75.

Findings include:

Review of personnel files for Care Partner #327 revealed that Care Partner #327 started working at the facility on 10/22/25. The facility did not have documentation within the employee record that Care Partner #327, who was unlicensed staff, received training or was evaluated regarding the correct techniques for providing personal care services by a Registered Nurse (RN), or by a Licensed Practical Nurse (LPN) under the direction of an RN.

Interview on 11/13/25 at 12:42 P.M. with the Director of Health and Wellness confirmed that Care Partner #327 was unlicensed, and the facility did not retain written documentation of the evaluation of the techniques within the personnel file for Care Partner #327.

Based on observation, and staff interview and policy review, the facility failed to ensure safe and sanitary storage of food. This had potential to affect all 75 residents in the facility. The facility census was 75. Findings include: Observation on 11/12/25 at 2:03 P.M. in the memory care unit kitchenette refrigerator revealed an undated, opened 46-ounce container of thick and easy cranberry juice cocktail and two four-ounce cartons of strawberry banana milkshake with a use-by date of 10/10/25. Interview on 11/12/25 at 2:35 P.M. with Memory Care Program Manager #347 confirmed the presence of the expired milkshake products in the refrigerator. Memory Care Program Manager #347 discarded the expired products at the time of the interview. Observation on 11/13/25 at 8:00 A.M. in the kitchen revealed the freezer contained a bag of boneless chicken wings open to air and a bag of chicken patties open to air. Interview on 11/13/25 at 8:15 A.M. with Director of Dining Services #238 verified the two meat items in the freezer were open to air and should be in a sealed storage container. Review of the facility policy titled, Food StorageBased on observation, and staff interview and policy review, the facility failed to ensure safe and sanitary storage of food. This had potential to affect all 75 residents in the facility. The facility census was 75.

Findings include:

Observation on 11/12/25 at 2:03 P.M. in the memory care unit kitchenette refrigerator revealed an undated, opened 46-ounce container of thick and easy cranberry juice cocktail and two four-ounce cartons of strawberry banana milkshake with a use-by date of 10/10/25.

Interview on 11/12/25 at 2:35 P.M. with Memory Care Program Manager #347 confirmed the presence of the expired milkshake products in the refrigerator. Memory Care Program Manager #347 discarded the expired products at the time of the interview.

Observation on 11/13/25 at 8:00 A.M. in the kitchen revealed the freezer contained a bag of boneless chicken wings open to air and a bag of chicken patties open to air.

Interview on 11/13/25 at 8:15 A.M. with Director of Dining Services #238 verified the two meat items in the freezer were open to air and should be in a sealed storage container.

Review of the facility policy titled, Food Storage

Based on record review, staff interview and policy review, the facility failed to ensure fire drills were conducted at a variety of times and on two occasions, failed to ensure alarm transmissions were confirmed within 12 hours. This had the potential to affect all 75 residents in the facility. The facility census was 75. Findings include: Review of monthly fire drill records from February 2025 to October 2025 revealed six of the nine fire drills were between the hours of 10:00 A.M. and 3:00 P.M. (02/27/25 at 2:55 P.M., 03/21/25 at 6:00 A.M., 04/30/25 at 10:11 A.M., 05/29/25 at 2:12 P.M., 07/30/25 at 1:05 P.M., 08/28/25 at 1:00 P.M., 10/30/25 at 11:30 A.M.). There were no fire drills conducted between the hours of 3:00 P.M. and 10:00 P.M. and no fire drills conducted between the hours of 11:00 P.M. and 6:00 A.M. There were only two evening fire drills that were conducted in the nine months and the times of the drill were within an hour from each other: at 10:00 P.M. on 06/01/25 and at 10:50 P.M. on 09/26/25. Review of the alarm company records revealed on 03/21/25 there was no alarm confirmation and on 09/26/25 the alarm transmission was not confirmed for 24 hours. Interview on 11/13/25 at 8:20 A.M. with Maintenance Director #351 confirmed the times of the fire drills and that there were two seven-hour blocks of time in which no fire drills were conducted. He also verified the alarm transmission verification did not happen within twelve hours following the 03/21/25 and 09/26/25 fire drills. Review of the facility policy titled, Fire DrillsBased on record review, staff interview and policy review, the facility failed to ensure fire drills were conducted at a variety of times and on two occasions, failed to ensure alarm transmissions were confirmed within 12 hours. This had the potential to affect all 75 residents in the facility. The facility census was 75.

Findings include:

Review of monthly fire drill records from February 2025 to October 2025 revealed six of the nine fire drills were between the hours of 10:00 A.M. and 3:00 P.M. (02/27/25 at 2:55 P.M., 03/21/25 at 6:00 A.M., 04/30/25 at 10:11 A.M., 05/29/25 at 2:12 P.M., 07/30/25 at 1:05 P.M., 08/28/25 at 1:00 P.M., 10/30/25 at 11:30 A.M.). There were no fire drills conducted between the hours of 3:00 P.M. and 10:00 P.M. and no fire drills conducted between the hours of 11:00 P.M. and 6:00 A.M. There were only two evening fire drills that were conducted in the nine months and the times of the drill were within an hour from each other: at 10:00 P.M. on 06/01/25 and at 10:50 P.M. on 09/26/25.

Review of the alarm company records revealed on 03/21/25 there was no alarm confirmation and on 09/26/25 the alarm transmission was not confirmed for 24 hours.

Interview on 11/13/25 at 8:20 A.M. with Maintenance Director #351 confirmed the times of the fire drills and that there were two seven-hour blocks of time in which no fire drills were conducted. He also verified the alarm transmission verification did not happen within twelve hours following the 03/21/25 and 09/26/25 fire drills.

Review of the facility policy titled, Fire Drills

Based on observation, staff interview, policy review, and Safety Data Sheet (SDS) review, the facility failed to ensure hazardous materials were stored appropriately and were not accessible to residents in the memory care unit. This had the potential to affect all 19 residents residing in the memory care unit. The facility census was 75. Findings include: Observation on 11/12/25 at 2:17 P.M. of unlocked lower kitchenette cabinet with spray bottle of rapid multi-surface disinfectant cleaner. Interview on 11/12/25 at 2:18 P.M. with Care Partner #361 confirmed presence of spray bottle of cleaner in unlocked cabinet. She smelled item and confirmed it had chemical smell and was not water. Care Partner #361 said cleaning supplies should be locked up and relocated the spray bottle to the locked janitor closet. Observation on 11/12/25 at 2:20 P.M. of an unlocked desk in the hallway of the memory care unit revealed the center desk drawer contained wet wipes with warning label that said 'store out of reach of children' and a four-ounce bottle of hand sanitizer with 65% alcohol content and a warning label that said keep out of reach of children. Interview on 11/12/25 at 2:30 P.M. with Memory Care Program Manager #347 confirmed the wipes and the hand sanitizer should not be left unsecured where residents could access them. Review of the facility policy titled, Resident Personal Care ItemsBased on observation, staff interview, policy review, and Safety Data Sheet (SDS) review, the facility failed to ensure hazardous materials were stored appropriately and were not accessible to residents in the memory care unit. This had the potential to affect all 19 residents residing in the memory care unit. The facility census was 75.

Findings include:

Observation on 11/12/25 at 2:17 P.M. of unlocked lower kitchenette cabinet with spray bottle of rapid multi-surface disinfectant cleaner.

Interview on 11/12/25 at 2:18 P.M. with Care Partner #361 confirmed presence of spray bottle of cleaner in unlocked cabinet. She smelled item and confirmed it had chemical smell and was not water. Care Partner #361 said cleaning supplies should be locked up and relocated the spray bottle to the locked janitor closet.

Observation on 11/12/25 at 2:20 P.M. of an unlocked desk in the hallway of the memory care unit revealed the center desk drawer contained wet wipes with warning label that said 'store out of reach of children' and a four-ounce bottle of hand sanitizer with 65% alcohol content and a warning label that said keep out of reach of children.

Interview on 11/12/25 at 2:30 P.M. with Memory Care Program Manager #347 confirmed the wipes and the hand sanitizer should not be left unsecured where residents could access them.

Review of the facility policy titled, Resident Personal Care Items

Based on medical record review, email message review, family interview, staff interview, and facility policy review, the facility failed to address a grievance in a timely and complete manner. This affected one (Resident #80) of three residents reviewed for grievances. The census was 75.

Findings Include:

Review of the closed medical record revealed Resident #80 was admitted to the facility on 06/02/22. His diagnoses included asthma, combined forms of age related cataracts, cerebral aneurysm, depression, hyperlipidemia, chronic kidney disease, hypokalemia, need for assistance with personal care, dementia, cognitive communication deficit, hypertensive heart disease, polyneuropathy, insomnia, encephalopathy, atrial flutter, atherosclerotic heart disease, occlusion and stenosis, hypertension, and chronic embolism and thrombosis. Resident #80 received hospice services and passed away at the facility on 07/17/25.

Review of Resident #80's Personal Services Assessment (PSA), dated 05/22/25, revealed he had a significant cognitive impairment.

Review of Resident #80's family emails, dated 07/31/25, revealed Resident #80 family contacted Business Office Manager (BOM) #70 and Maintenance Director #55 about furniture that would be picked up by movers. Maintenance Director #55 stated he did not know which one was Resident #80 twin sized bed; stating there were two beds in storage and most likely it had been taken to the dumpster. There were no further conversations or communications about this matter.

Interview with Resident #80's family on 08/20/25 at 2:28 P.M. confirmed she only spoke with Maintenance Director #55 via email. He told her that he thought the resident's bed had been taken to the dumpster while they were cleaning out storage areas and empty rooms. She confirmed she did not receive an apology, which was the most important thing she wanted. She confirmed she was not aware if the facility did an investigation as to what actually happened to the bed.

Interview with Health and Wellness Director #6 and the Executive Director (ED) #100 on 08/20/25 at 2:10 P.M. and 2:20 P.M. revealed they just found out today about the bed being taken to the dumpster. They confirmed they were unaware of this situation, so they did not do an investigation. They confirmed they had not spoken to Resident #80's family about Resident #80's bed.

Interview with Maintenance Director #55 on 08/20/25 at 2:50 P.M. confirmed he spoke with Resident #80's family via email to clarify what they were looking for, and then to report to them that he feels the bed may have been taken to the dumpster as they were cleaning out open rooms that had stored furniture in them. He confirmed he never spoke with her on the phone. He also stated he would love to apologize to her if he ever talked to her again.

Review of facility Grievance Policy, dated March 2022, revealed the resident and responsible party may express a formal grievance or recommend changes in policy, procedures, and services to the following: associates, governing officials, or any other person without restraint, interference, coercion, discrimination, or reprisal. When a grievance has been submitted, the ED or district/regional director of operations will follow the grievance procedure. The ED or district/regional director of operations will document actions taken in response to the grievance. The ED may document these actions on a grievance log.

Review of facility grievance log, dated July 2025 to August 2025, revealed no grievances had been filed on behalf of Resident #80 regarding the missing bed.

This violation represents non-compliance investigated under Complaint Number OH00167806.

Based on review of personnel files and staff interview, the facility failed to retain proof that unlicensed direct care staff had received training, by a registered nurse (RN) or by a licensed practical nurse (LPN) under the direction of an RN, regarding the correct techniques for providing personal care services. This had the potential to affect all 77 residents residing in the facility.

Findings include:

Review of personnel files for Care Partner #105 and Care Partner #138 revealed that the facility did not have proof that the Care Partners, who were unlicensed staff, received training regarding the correct techniques for providing personal care services by an RN, or by an LPN under the direction of an RN.

Interview with the Director of Wellness on 02/11/25 at 4:38 P.M. confirmed that the facility did not retain written proof of the education of unlicensed staff for personal care services. Further interview revealed the areas that unlicensed staff should be trained on, by an RN, or by an LPN under the direction of an RN, would include perineal care, mouth care, assisting in transfers and bathing, all of which were necessary components of the Care Partner's daily duties.

Based on record review, resident interview, staff interview, observation, and review of facility policy, the facility failed to properly store medications in a safe manner for Resident #22 and failed to store medications properly in medication carts for B and C units. This affected one resident (#22) and had the potential to affect all 23 residents (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #75) receiving medications on B unit and all 24 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #72, #73) receiving medications on C unit. The facility census was 77.

Findings include:

1. Review of Resident #22's medical record revealed that he was admitted on 01/25/20 with diagnoses that included atopic dermatitis, congestive heart failure, diabetes mellitus, hypertension, hypothyroidism and atherosclerotic heart disease.

Review of Resident #22's Personal Service Assessment dated 11/07/24 revealed the resident needed assistance with coordinating/storage of meds and he required staff attention and/or physical assistance taking medications.

Review of Resident #22's Service Plan dated 11/17/24 revealed the resident required a nurse to administer medications.

Review of physicians orders for February 2025 revealed orders for a nurse or licensed staff to administer medications. There were additional orders for Diclofenac Sodium External Gel 1% with instructions to apply 2 grams to bilateral shoulders topically three times daily for pain and to apply 2 grams to the right elbow topically four times daily as needed for pain, Camphor-Menthol External Lotion 0.5%-0.5% with instructions to apply to arms, chest, and legs topically twice daily for xerosis, and Triamcinolone Acetonide External Cream 0.1% with instructions to apply to rash twice daily for atopic dermatitis. There was no evidence of an order for Chlorhexidine Gluconate.

Review of the Medications Administration Record and Treatment Administration Record for February 2025 revealed that nurses had been administering all medications and treatments including Camphor-Menthol External Lotion, Diclofenac Sodium External Gel and Triamcinolone Cream.

Observation of medication administration for Resident #22 on 02/11/25 at 8:00 A.M. with Registered Nurse (RN) #100 revealed the following medications/treatments at the residents bedside: Diclofenac Gel, Camphor-Menthol Lotion and Triamcinolone Cream. Chlorhexidine Gluconate was found in Resident #22's bathroom and revealed a pharmacy label with a discard-after date of 04/05/23.

Interview with Resident #22 on 02/11/25 at 8:10 A.M. revealed that he self-administered Chlorahexadine Gluconate daily in the morning.

Interview on 02/11/25 at 8:11 A.M. with RN #100 verified the expiration date of 04/05/23 on the Chlorahexadine Gluconate and that the Camphor-Menthol Lotion, Triamcinolone cream and Diclofenac Gel medications were left at bedside.

2. Interview and observation of Medication Cart-A on 02/11/25 at 8:30 A.M. with Registered Nurse (RN) #100 revealed six medicine cups in the top drawer with unknown pills with numbers and letters on them. RN #100 stated they were for some residents that were in the dining room, she was waiting on them to come back to the unit to give them their medications.

3. Interview and observation of Medication Cart-B on 02/11/25 at 9:15 A.M. with Licensed Practical Nurse (LPN) #113 revealed in the top drawer of the medication cart there was an unknown pill in a medicine cup with a first name written on the cup. LPN #113 stated that she was trying to save it for a resident for a later medication pass administration.

Review of the policy titled, Medication & Treatment - Storage, dated October 2006 revealed that medications and treatments should be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions and that medications, treatments and dietary supplements shall be kept in their original containers.

Review of the policy titled, Medication & Treatment- Administration/Assistance, dated August 2010 revealed that medication administration/assistance and/or treatment shall be provided in a safe and timely manner, and as prescribed by the resident's physician/healthcare provider and that the individual assisting and or administering the medication should check the label three times to verify the right medication, right dosage, right time and right method of administration before giving the medication. Medications may not be prepared in advance unless permitted by state regulation.

Based on review of employee files and staff interview, the facility failed to retain proof of staff receiving education related to residents' rights advocates in the staff personnel files. This had the potential to affect all 77 residents residing in the facility.

Findings include:

Review of employee personnel records for Licensed Practical Nurse (LPN) #146, LPN #161, LPN #103, Care Partner #105, and Care Partner #138 revealed no written proof of education related to residents' rights advocates in the staff personnel files.

Interview with the Business Office Manager #102 on 02/11/25 at 4:23 P.M. confirmed that the facility did not keep a written record of education related to residents' rights advocates in the staff personnel files.

Based on resident interview, staff interview, and record review, the facility failed to maintain accurate documentation of a resident's choice regarding power of attorney. This affected one resident (#27) out of seven residents reviewed for accurate documentation. This had potential to affect all 77 residents.

Findings include:

Review of Resident #27's record revealed he was admitted on 10/01/21 with diagnoses including chronic obstructive pulmonary disease (COPD), hypothyroidism, chronic kidney disease stage 3, diastolic (congestive) heart failure, schizoaffective disorder, bipolar type, personality disorder. His face sheet indicated that his family member was listed as Health Care and Financial Power of Attorney (POA).

Interview on 02/11/25 at 10:00 A.M. with Resident #27 confirmed that he had revoked the POA designation for his family member.

Interview on 02/11/25 at 4:49 P.M. with Business Office Manager #102 verified that he had received an e-mail dated 10/29/24 which stated Resident #27's family member was no longer serving as his POA.

Interview on 02/11/25 at 5:44 P.M. with Executive Director verified that Resident #27's family member was no longer his Health Care POA. The Executive Director confirmed that the medical record stated that the residents family member was Health Care and Financial POA, that it was inaccurate, and that it should have been changed.