Brookdale Zanesville

Based on observation, staff interview, and policy review, the facility failed to follow infection control procedures during a wound dressing change. This affected one (Resident #52) of one resident reviewed for wound care. The facility census was 76.

Findings include:

Observation on 11/21/24 at 10:30 A.M. revealed Director of Nursing (DON) completed Resident #52's wound dressing change. The DON applied gloves, removed the soiled dressing, removed her soiled gloves, and applied a new pair of gloves without performing hand hygiene. The DON performed the dressing change for Resident #52, and at the conclusion of the dressing change, removed her gloves and performed hand hygiene.

Interview on 11/21/24 at 5:45 P.M. with DON confirmed during wound care, she failed to perform hand hygiene each time she changed her gloves.

Review of the policy Communicable Disease Control, revised 4/01/24, revealed associates will be made aware of ways to prevent and reduce the spread of infectious diseases. These measures included, but were not limited to, practicing effective hand washing procedures.

Based on observation, interview, and policy review, the facility failed to discard expired items and keep a sanitary kitchen. This had the potential to affect all residents in the facility who received meals from the kitchen. The facility census was 76.

Findings include:

Observations on 11/21/24 between 8:24 A.M. and 9:00 A.M. in the facility kitchen revealed the following:

1. Approximately 5 wet, plastic containers stacked on each other.

2. Grime and grease covered the inside and outside of the oven and lower shelves of the food prep table.

3. The garbage can was visibly soiled with an unknown substance.

4. A 32-ounce container of herbs de provence listed an expiration date of 10/14/24.

5. A 1-pound (lb) container of salt substitute listed an expiration date of 11/01/24.

6. A 1-lb container of poultry seasoning listed an expiration date of 10/14/24.

7. A 1-lb container of ground coriander listed an expiration date of 10/01/24.

8. A 1-lb container of ground turmeric listed an expiration date of 09/13/24.

9. A 1-lb container of ground rosemary listed an expiration date of 10/24/24.

10. A 1-lb container of dill weed listed an expiration date of 08/08/24.

11. A 1-lb container of cajun seasoning listed an expiration date of 02/08/24.

12. A 5-lb bag of wide egg noodles were opened and undated.

Interview on 11/21/24 at 9 A.M. with Cook #165 confirmed the above findings.

Review of the policy Food Storage dated June 2024 revealed all foods must be stored in a manner that maximizes nutrient retention, quality, and food safety. The storerooms should be maintained free from dirt and dust or any potential sources of contamination.

Based on review of personnel files and interview, the facility failed to ensure all staff received a written receipt of transfer/discharge provisions as required. This had the potential to affect all residents residing in the facility. The facility census was 76.

Findings include:

Review of personnel files for Caregivers #108 and #125, Director of Nursing (DON), and Business Office Manager (BOM) #123 revealed there was no written receipt of education for transfer/discharge resident provisions as required.

An email containing additional information for review on 11/22/24 at 1:10 P.M. from the Administrator confirmed there was no written receipt of transfer/discharge provisions.

Based on observations, staff interview, and review of employee time sheets, the facility failed to provide adequate staffing levels to meet the resident's needs. This could affect all 78 residents residing in the facility.

Findings include:

Interview with the Health and Wellness Director/Licensed Practical Nurse (LPN) #119 on 10/26/23 at 9:50 A.M. revealed the facility required two nurses on day shift (6 am- 2 pm), two nurses on evening shift (2 pm-10 pm) and one nurse on night shift (10 pm to 6 am). It required two resident assistants on the assisted living side and two resident assistants on the memory care side every shift (6 am-2 pm, 2 pm-10 pm, and 10 pm - 6 am). She stated there were 22 residents on the memory care unit who were all cognitively impaired and required a nurse to administer their medications. She stated there were 56 residents on the assisted living side with 22 of them requiring a nurse to administer their medications (44 total requiring medication administration).

Observations on 10/19/23 at 10:00 A.M. revealed there was one nurse for the facility, one resident assistant on the assisted living side and two resident assistants for the memory care unit.

Interview with Resident #7 on 10/19/23 at 10:10 A.M. revealed there was not enough staff at times to meet his needs timely.

Interview with Resident #32 on 10/24/23 at 8:50 A.M. revealed there was not enough staff at times to meet her needs timely.

Review of the medical record for Resident #72 (admitted 06/24/17 and residing on the memory care unit) revealed a nurses note on 10/24/23 at 8:48 A.M. by the Administrator which stated the resident's daughter had called many times over the weekend. Was about staffing. Explained staffing was appropriate and she was unable to believe stating she had just left. Hopes to get mother relocated.

Observations on 10/24/23 at 8:00 A.M. revealed there was one resident assistant (RA) working on the memory care unit (RA #107). There was one nurse working in the facility but she was not on the memory care unit at that time. At that time, RA #107 stated she was the only person providing care on the memory care unit. She stated the 22 residents on memory care had to eat breakfast in their rooms because she was unable to get everyone up and dressed so they could come out to the dining room for breakfast.

Observations on 10/24/23 at 9:30 A.M. revealed there was one resident sitting in the living room area of the memory care unit. All other residents were still in their rooms. Ten residents were still in bed. LPN #119 confirmed, at that time, that all residents, except one, were still in their rooms either in bed or in a chair. RA #107 stated, at that time, that all residents are normally up and dressed for breakfast in the dining room. She stated she told LPN #119 the day before that she was the only resident assistant scheduled for day shift on 10/24/23. RA #107 stated there are four residents on memory care who require two staff for transfers, so she is unable to get them up when there is only one staff. She stated she was the only staff person on memory care on 10/22/23 also. She stated she had to serve breakfast in resident rooms then also.

Review of staff time sheets confirmed there was only one resident assistant working on memory care on day shift on 10/22/23 and 10/24/23.

Observations on 10/24/23 at 9:25 A.M. revealed Housekeeper #80 was in Resident #62's room. She stated she was assisting with getting him dressed. She confirmed she had not been trained to provide personal care to residents. LPN #119 confirmed at that time that Housekeeper #80 was assisting with resident care.

Interview with Memory Care Program Director #94 on 10/24/23 at 10:45 A.M. revealed she typically worked Monday through Friday from 8:30 A.M. to 5:00 P.M. to provide activities for memory care. She stated she had not been trained to provide personal care for residents. She stated she had worked at the facility one month and had recently worked providing personal care for residents three times on midnight shift. She stated they were supposed to have two aides on memory care on each shift. She stated she had worked from 10 pm to 5:30 am on 10/23/23 on memory care providing personal care for residents with one other aide until 2:30 A.M. From 2:30 am to 5:30 am she worked by herself on the memory care unit providing personal care for residents. She stated she knew there was only one aide scheduled for day shift on memory care on 10/24/23 so that is why she came back into work at 10:00 A.M. on 10/24/23 to provide activities for residents. She confirmed that all residents but three usually eat their meals in the dining room. She confirmed one staff would be unable to get residents up and dressed and to the dining room for breakfast. She stated she felt they were short staffed on the memory care unit.

Observations and interview with RA #88 on 10/26/23 at 2:45 P.M. revealed she was the only resident assistant working on the memory care unit at that time. She stated she would be unable to assist the residents who require two person assistance and would have to pull the one aide working on the assisted living unit.

Review of staff time sheets and staff schedules from 10/13/23 to 10/25/23 with LPN #119 revealed 12 of 13 days had only one nurse on days shift. Seven of 13 days had only one nurse on evening shift. Six of 13 days had no nurse on night shift and seven of 13 days had one nurse on night shift. This was confirmed by LPN #119.

When reviewing the nurses schedule, there were names on the schedule to appear as though the shifts were covered by a nurse. However, the names listed were not nurses and included the front desk clerk, and activities staff. This was confirmed by LPN #119 on 10/26/23 at 9:50 A.M.

Review of staff time sheets and staff schedules from 10/13/23 to 10/25/23 with LPN #119 revealed there was one aide on the memory care unit on days shift on four of 13 days. There was one aide on memory care on evening shift on four of 13 days. There was one aide on memory care on night shift on eight of 13 days. There was one aide on assisted living side on day shift on 11 of 13 days. There was one aide on assisted living side on evening shift on 7 of 13 days. There was one aide on assisted living side on night shift on 13 of 13 days.

Based on review of employee personnel files and staff interview, the facility failed to ensure staff who provide personal care services were provided with first-aid training within sixty days of hire. This was discovered with two of two new employees reviewed who had been employed more than sixty days and had the potential to affect all 78 residents. The facility census was 78.

Findings include:

1. Review of the personnel file for Resident Assistant #101 revealed a hire date of 11/22/22. There was no evidence first aide training had been provided as required.

This was confirmed by Administrator #115 on 10/24/23 at 3:20 P.M.

2. Review of the personnel file for Resident Assistant #107 revealed a hire date of 08/15/23. There was no evidence first aide training had been provided as required.

This was confirmed by Administrator #115 on 10/24/23 at 3:20 P.M.

Based on review of employee personnel files, observations, and staff interview, the facility failed to ensure staff providing personal care for residents had been adequately trained as required. This was discovered in three of three resident assistants hired in the past year whose files were reviewed. It was also discovered with two staff from other departments who were providing personal care. This had the potential to affect all 78 residents.

Findings include:

1. Review of the employee file for Resident Assistant (RA) #107 revealed a hire date of 08/15/23. There was no evidence she had been provided with training on providing personal care services as required.

This was confirmed by Administrator #115 on 10/24/23 at 3:20 P.M.

2. Review of the employee file for Resident Assistant (RA) #101 revealed a hire date of 11/22/22. There was no evidence she had been provided with training on providing personal care services as required.

This was confirmed by Administrator #115 on 10/24/23 at 3:20 P.M.

3. Review of the employee file for Resident Assistant (RA) #113 revealed a hire date of 08/29/23. There was no evidence she had been provided with training on providing personal care services as required.

This was confirmed by Administrator #115 on 10/24/23 at 3:20 P.M.

4. Interview with RA #104 and #113 on 10/25/23 at approximately 2:30 P.M. revealed they felt they were not adequately trained to provide personal care for residents. Interview with RA #93 on 10/25/23 at 9:00 A.M. revealed she felt she was not adequately trained to provide personal care for residents. She had worked at the facility for two months.

5. Observations on 10/24/23 at 9:25 A.M. revealed Housekeeper #80 was in Resident #62's room. She stated she was assisting with getting him dressed. She confirmed she had not been trained to provide personal care to residents. LPN #119 confirmed at that time that Housekeeper #80 was assisting with resident care.

6. Interview with Memory Care Program Director #94 on 10/24/23 at 10:45 A.M. revealed she typically worked Monday through Friday from 8:30 A.M. to 5:00 P.M. to provide activities for memory care. She stated she had not been trained to provide personal care for residents. She stated she had worked at the facility one month and had recently worked providing personal care for residents three times on midnight shift. She stated they were supposed to have two aides on memory care on each shift. She stated she had worked from 10 pm to 5:30 am on 10/23/23 on memory care providing personal care for residents with one other aide until 2:30 A.M. From 2:30 am to 5:30 am she worked by herself on the memory care unit providing personal care for residents.

Interview with Administrator #115 on 10/24/23 at 3:20 P.M. confirmed Housekeeper #80 and Memory Care Program Director #94 had not been trained to provide personal care to residents.

Based on medical record review and staff interview, the facility failed to accurately assess residents for fall risk for three of five sampled residents (Residents #5, #60, and #77) and failed to obtain a determination by a physician to determine if a resident was capable of self-administering medications for one of five sampled residents (Resident #77). The facility census was 78.

Findings include:

1. Review of the medical record for Resident #77 revealed an admission date of 10/07/23. There was no evidence a determination had been made by a physician to determine if the resident was capable of self-administering medications. The resident was self administering his own medications.

In addition, a fall risk assessment completed 10/11/23 noted the resident had problems ambulating and transferring. This was listed under the level 3 risk for falls and should have made him a level 3 risk for falls (level 1= low risk, level 2= moderate risk and level 3= high fall risk). However, the resident was determined to be a level 1 falls risk.

Interview with Corporate Registered Nurse #126 on 10/25/23 at 11:00 A.M. confirmed a determination on self administration of medications had not been obtained and confirmed the fall risk assessment was not accurate.

2. Review of the medical record for Resident #60 revealed an admission date of 05/23/23. A fall risk assessment completed 05/24/23 noted the resident had problems ambulating or transferring. This was listed under the level 3 risk for falls and should have made her a level 3 risk for falls (level 1= low risk, level 2= moderate risk and level 3= high fall risk). However, the resident was determined to be a level 2 falls risk.

Interview with Corporate Registered Nurse #126 on 10/25/23 at 11:00 A.M. confirmed the fall risk assessment was not accurate.

3. Review of the medical record for Resident #5 revealed an admission date of 03/05/23. A fall risk assessment completed 03/05/23 noted the resident had problems ambulating or transferring. This was listed under the level 3 risk for falls and should have made her a level 3 risk for falls (level 1= low risk, level 2= moderate risk and level 3= high fall risk). However, the resident was determined to be a level 2 falls risk.

Interview with Corporate Registered Nurse #126 on 10/25/23 at 11:00 A.M. confirmed the fall risk assessment was not accurate.

Based on observations, staff interview, and policy review, the facility failed to ensure appropriate infection control techniques were followed during the provision of incontinence care. This affected one resident observed for incontinence care (Resident #11). The facility census was 78.

Findings include:

Observations on 10/25/23 at 2:20 P.M. revealed Resident Assistant (RA) #104 and #113 to provide incontinence care for Resident #11 while the resident was in bed. RA #104 used a wet washcloth with soap to cleanse the resident's perineal area. She used a second wet washcloth with soap to cleanse the resident's rectal area. RA #104 rinsed out both washcloths in the resident's kitchen sink (not the bathroom sink). She laid the soiled washcloths in the bowl of the kitchen sink.

In addition, RA #104 used the same area of the washcloth to wash front to back repeatedly on the resident's perineal area. She did not use a clean area of the washcloth with each stroke from front to back. Therefore, the dirty area of the washcloth was repeatedly moved upward towards the urethra, with the potential for urinary tract infection.

Both staff were observed, at that time, to wash their hands before and after incontinence care in the resident's kitchen sink.

Interview with RA #104 on 10/25/23 at approximately 2:30 P.M. confirmed the above. RA #104 and RA #113 stated they were both trained to use the kitchen sink to rinse out the soiled linens. RA #104 stated she was aware you should cleanse from front to back for a female during incontinence care but was not aware you needed to use clean areas of the washcloth with each stroke. Both RA #104 and #113 stated they felt they were not adequately trained to provide personal care for residents.

Interview with Corporate Registered Nurse #126 on 10/25/23 at 2:55 P.M. confirmed staff should not use the kitchen sink during incontinence care. She further confirmed the same part of the washcloth should not be used from front to back on multiple strokes during incontinence care for a female resident.

Review of the facility policy on incontinence care dated June 2002 and revised August 2022 revealed it indicated disposable wipes were to be used. The policy did not address what sink to use but indicated the incontinence care would be provided in the bathroom. It stated to encourage the resident to clean the perineal area in a front to back motion and to provide assistance as needed. The wipes were to be disposed of in a trash bag.

Based on review of employee personnel files, review of the facility policy on Tuberculosis Control, and staff interview, the facility failed to follow their tuberculosis control plan. This occurred with two of two employees reviewed who had been employed greater than one year and could affect all 78 residents residing in the facility.

Findings include:

Review of the facility policy titled Tuberculosis Control Plan dated 11/2015 and last revised 12/2022 revealed a tuberculosis surveillance questionnaire would be completed by each staff person annually to screen for any signs/symptoms of tuberculosis.

Review of Administrator #115's personnel file revealed a hire date of April 2015. There was no evidence a tuberculosis surveillance questionnaire had been completed in the past year.

Review of Resident Assistant #92's personnel file revealed a hire date of 09/18/20. There was no evidence a tuberculosis surveillance questionnaire had been completed in the past year.

Interview with Corporate Registered Nurse #126 on 10/25/23 at 1:40 P.M. confirmed there was no evidence annual tuberculosis surveillance had been completed in the past year.

Based on observations, review of dietary spread sheets, and staff interview, the facility failed to ensure the spread sheets had the correct portion sizes for foods served. This could affect all 78 residents residing in the facility.

Findings include:

The facility provides three meals daily.

Observations of the lunch tray line on 10/25/23 at 12:00 P.M. revealed a pasta casserole was served. A #6 (4.5 ounce) scoop was used to serve the pasta. Egg salad was an alternate. A green, 2.75 ounce scoop was used to serve the egg salad.

Review of the facility spread sheets revealed it called for 12 ounces of the pasta casserole to be served. It called for 9 ounces of the egg salad to be served with each portion.

Interview with Dietary Manager #108 on 10/25/23 at 1:50 P.M. revealed the spread sheets were wrong for the serving sizes. He stated the spread sheets needed to be revised to ensure the correct serving sizes were included.

Based on observations, staff interview, and review of facility logs, the facility failed to implement housekeeping procedures to ensure a safe environment. This could affect all 78 residents residing in the facility.

Findings include:

Observations on 10/25/23 at 8:25 A.M. of the facility laundry revealed two dryers with an excessive build up of lint in the lint traps and a build up of lint behind the dryers.

There was a sign on the wall in the laundry that stated the lint was to be cleaned after every load and to sign off on a log hanging on the wall.

Review of the lint cleaning log revealed the last documentation was from July 2023.

This was confirmed by Maintenance Director #121 at the time of the observations.

Based on observations and staff interview, the facility failed to provide a clean living environment. This could affect all 78 residents residing in the facility.

Findings include:

Observations on 10/25/23 at 8:35 A.M. revealed the following:

eight large stains in the carpet in the main hallway on A Hall,

nine large stains in the carpet in the main hallway on B Hall, and

six large stains in the carpet in the main hallway on C Hall.

Interview with Maintenance Supervisor #121 on 10/25/23 at 9:04 A.M. confirmed the stains in the carpets in the main hallways. He stated that even though the carpets are cleaned weekly, it does not do much good as the stains reappear in a couple days.

Based on review of a facility investigation report, review of a self reported incident form, review of the facility policy on abuse, observations, staff interview, and resident interview, the facility failed to ensure residents were free from abuse and were treated at all times with respect and dignity. Allegations of abuse were made by two staff and two residents against Resident Assistant #107. This affected Residents #60, #72, and two residents who wished to remain anonymous. The facility census was 78.

Findings include:

Review of a self reported incident form revealed the facility reported to the State Survey Agency on 10/13/23 an allegation of sexual abuse. The report stated that a facility caregiver (Resident Assistant #127) made an allegation that Resident Assistant (RA)#107 sexually assaulted Resident #72, who resided on the memory care unit, by touching her nipples during patient care and telling her that she stunk. RA #107 was suspended pending investigation. The facility documented that the allegation was unfounded through the process of interviews with 25 staff members, one resident, and one family member. The facility documented that RA#127 had withdrawn the statement. The allegation was unsubstantiated. The facility documented that re-education would be provided on abuse, patient care, and resident rights to all staff.

Review of the facility investigation report by Administrator #115 on 10/11/23 revealed the type of alleged incident was a sexual abuse allegation. It stated RA #127 alleged on 10/11/23 that RA #107 sexually assaulted Resident #72 in front of her by touching the resident's nipples and telling her she stunk. Resident #72 was interviewed on 10/11/23 at 6:00 P.M. and did not recall the incident. Interview with RA #127 on 10/11/23 at 3:45 P.M., 10/11/23 at 4:01 P.M. and 10/11/23 at 4:40 P.M. revealed she alleged while she and RA #107 were providing care to Resident #72, she watched RA #107 sexually assault the resident. The investigation stated RA #127 changed her description of what happened three times. RA #127 stated she heard RA #107 tell Resident #72 that she stunk. She told the resident to place her hand down in her perineal area and smell it. RA #127 also stated RA #107 touched the residents nipples with her hands teasing and swatting. She indicated the resident spit at the staff. It was documented that on 10/13/23 at 6:00 A.M. RA #127 withdrew her allegation of abuse. After further questioning about when the incident occurred, RA #127 cursed the Administrator, threw her keys and name badge, and was asked to leave. The police was called to get her to leave as she continued to cuss and scream profanity. Interview with RA #107 on 10/11/23 at 4:15 P.M. revealed she told Resident #72 she needed to be clean and she wanted to smell fresh. She handed the resident a wipe and told her to wash her arm pits as they smelled bad. RA #107 washed her chest and didn't do anything but care. 23 additional staff interviews were conducted by the facility with no other staff indicating any type of abuse witnessed. Resident #72's daughter was interviewed on 10/12/23 and said her mother was fine when she came to pick her up after the alleged incident. She did state the resident had short term memory loss. The investigation stated the allegation of sexual abuse was unfounded.

RA #127 (person making allegation) no longer worked at the facility after 10/13/23. RA #107 (alleged perpetrator) returned to work and was still working at the facility 10/24/23.

Interview with former RA #127 on 10/19/23 at 12:00 P.M. revealed on 10/10/23 she worked with RA #107 on the memory care unit. She stated RA #107 does not like Resident #72. She stated on that day, RA #107 aggressively pulled a blanket off the resident's head and told her it was time to get up. The resident was taken to the bathroom. RA #107 said why are you so ugly, you look like Donald Trump (to Resident #72). RA #107 said, do you stink? and told the resident to scratch her crotch and smell it. She stated RA #107 then demonstrated by scratching her crotch and smelling it. She told the resident to do that and the resident said no. She stated RA #107 then flipped the resident's nipples (no bra on). She said Resident #72 spit at them. She said she reported this to the Administrator. She stated RA #107 also, on the same day as the incident with Resident #72, went into Resident #60's room and said: if I was as fat as her, I would lay around all day too. The resident's shirt was up and she asked the resident why her titties were out. She asked the resident if her husband had come in and raped her. Resident #60 said no. (Resident #60 also resided on the memory care unit and had cognitive impairment). She stated the Administrator wanted her to drop her allegation of sexual abuse. She stated she still felt it was sexual harassment (flipping the resident's breast and demonstrating scratching her crotch).

Review of employee personnel files revealed RA #107 began working at the facility on 08/15/23 and RA #127 began working at the facility on 09/21/23.

Interview with a staff person who wished to remain anonymous on 10/19/23 revealed he/she had previously reported RA #107 to the Administrator (last month) and was fearful for his/her job. He/she stated RA #107 is mean to residents sometimes. She yells at residents because they get on her nerves. She has called residents fat ass. The staff person said the last person that reported RA #107 got fired. He/she stated everybody knows RA #107 does it. He/she stated RA #107 was not patient or kind with residents and felt other staff were afraid to say anything.

Interview with a resident who wished to remain anonymous on 10/24/23 revealed RA #107 was rude and disrespectful to him/her. He/she stated he/she had reported this to the Administrator a couple months ago.

Interview with an additional resident who wished to remain anonymous on 10/24/23 revealed RA #107 was rude to him/her. He/she stated he/she had asked for RA #107 not to provide care for him/her anymore. He/she stated it was reported to the Administrator about a month ago.

Interview with Administrator #115 (who had worked at the facility since 2015) on 10/24/23 at 11:30 A.M. revealed she was not aware of any other staff or resident allegations of abuse or mistreatment by RA #107.

Observations on 10/24/23 at 8:00 A.M. revealed RA #107 was the only resident assistant working on the memory care unit where 22 cognitively impaired residents resided. The nurse for the facility was not on the unit at the time. RA #107 confirmed she was the only staff person providing care on the unit.

Review of the facility policy titled Abuse, Neglect, and Exploitation dated 10/2001 and last revised 10/2002 revealed the facility is committed to maintaining a safe environment for each resident, visitor, and employee. Instances or allegations of abuse, neglect, or exploitation should be treated seriously and must be reported to the Executive Director or the supervisor on duty for investigation and appropriate follow up.

This violation represents non-compliance investigated under Complaint Number OH00147404.

Based on medical record review and staff interview, the facility failed to ensure residents were weighed as ordered by the physician. This affected three of five sampled residents (Residents #5, #32, and #72). The facility census was 78.

Findings include:

1. Review of the medical record for Resident #5 revealed an admission date of 03/05/23. The resident had a physician's order for monthly weights upon admission. There was no evidence the resident had been weighed since 08/20/23 at 181 pounds.

2. Review of the medical record for Resident #32 revealed an admission date of 11/4/22. The resident had a physician's order for monthly weights upon admission. There was no evidence the resident had been weighed since 08/20/23 at 253 pounds.

3. Review of the medical record for Resident #72 revealed an admission date of 06/24/17. There was no evidence the resident had been weighed since July 2023 at 152 pounds.

Interview with Corporate Registered Nurse #126 on 10/26/23 at 9:00 A.M. revealed residents are to be weighed monthly. She confirmed the residents had not been weighed since July or August 2023.