Brookdale Troy

Based on facility document review, staff interview, police administrative assistant interview, review of employee records, review of the associate handbook, and review of the police department incident, the facility failed to ensure staff adhered to the facility employee handbook when a facility Care Partner failed to report being arrested and charged with assault by law enforcement. This had the potential to affect all 51 residents who resided in the facility. The facility census was 51.

Findings Included:

Review of the facility document titled Ohio Application for Employment-Addendum date unknown revealed that a new employee was to sign and agree to information that understood by law that they had a position as new employee, and understood, was not permitted to work in the assisted living industry in the state of Ohio if they had ever been a resident of the state of Ohio for the last five or more years that had been convicted of or pleaded guilty to any of the of following crimes: murder, voluntary or involuntary manslaughter, assault, menacing, patient abuse or neglect, kidnapping or abduction, disseminating matter harmful to juveniles, domestic violence, trafficking, drug abuse, illegal processing drug document, robbery, and burglary. Employees understood if offered employment at the facility, they would be conditionally employed until the return of their criminal background check. Therefore, certifying that the employee had never been convicted of or pleaded guilty to any of the crimes mentioned above.

Review of the facility Associate Handbook dated 2024 revealed under the section criminal background checks that during your employment with facility, you may be required, depending on your position and in accordance with application law, to report certain criminal convictions that occur during your employment to your supervisor. Failing to provide information or providing inaccurate or incomplete information to facility regarding your conviction record or with regard to pending charges at any time, including while employed by facility, was grounds for immediate termination of employment, subject to applicable law.

Review of the employee record for Care Partner (CP) #222 revealed she was hired on 09/15/25. Training included associate handbooks, infection control, identifying, preventing and reporting abuse. CP #222 had signed her acknowledgement of code of business conduct, ethics, and agreed that she understood the principles.

Review of the facility document titled Associate Handbook Receipt and Acknowledgement dated 09/15/25 was signed by CP #222 that stated she acknowledge that it was her responsibility to read the handbook and comply with the terms given in the handbook. The company had the right to assume that if she fails to ask for clarification of any issue or policy contained in the handbook, that the person understood the entire handbook. Also, CP #222 had been provided with information about false claims laws for the state in which they worked in.

Review of facility document titled Position Apply For dated 09/09/25 revealed that CP #222 applied for a care giver position at the facility. CP #222 had answered No to having ever been convicted of, pled guilty, and no contest. CP #222 also answered No to not awaiting trial or sentencing for any offense. CP #222 answered No to ever initiate or act in violence in the workplace. CP #222 had signed that she acknowledged and understood that any misrepresentation or missing facts, can call for refusal to hire; or to be dismissed at any time due to actions.

Review of the Brookville Police Department Incident #2025-00388 dated 08/20/25 revealed CP #222 had assaulted a police officer at her home address after her children were taken away by children services. After children were removed from the home, CP #222 made a comment about killing herself to the police officer. CP #222 attempted to shut her front door from the police officer, but the police officer blocked the door from closing with his shoe. Police officer followed her in her home, to ask her again to come with him to go to the hospital to be evaluated. Police officer reached for CP #222 who refused to go and turned away her arm from being taken. CP #222 fell to the floor and refused again to be taken to be evaluated at the hospital. Police officer reached for CP #222 when she began kicking and hitting him. Police officer positioned CP #222 to take her safely, arranged for police back up, and wrote a pink slip to have her evaluated at the hospital. CP #222 was dropped off at the hospital by police.

Interview on 03/26/26 at 10:58 A.M. with Executive Director (ED) stated she started working at the facility two weeks ago. The ED stated with a new employee the facility checked the nurse registry, background check, at time of the hire date. The facility does not do annual background check. Our employee handbook says that if an employee is arrested, they have 24 hours to notify the facility of arrest. ED stated the employee at time of hire also signs a handbook that if they have a record that disqualifies them to work in a facility. ED stated if she was notified by employees that they had been arrested, she would not have them work. ED would also look into what was going on to make sure her residents were safe. ED stated she was not aware of any current employees who had been arrested or charged.

Interview on 03/26/26 at 11:00 A.M. with Wellness Director (WD) who stated she had no knowledge of any employee who was currently working that had been arrested, charged, or had done unlawful actions.

Interview on 03/26/26 at 11:13 A.M. the former Executive Director who stated he was unaware that Care Partner (CP) #222 was arrested for assaulting a police officer. The former ED stated that he only knew that her and her husband had been going through a divorce and had problems. The former ED stated she did take time off in attending court appointments. The former ED stated he never looked into the concern because she was a good employee that showed up at work. The former ED stated she never was in trouble, had resident complaints, or had been investigated for abuse while he was overseeing the facility. The former ED stated if he was notified that she had been arrested, he would have reached out to human resources for direction. The former ED stated he could not remember what was in the employee handbook about notifying the management if an employee had arrests, convictions, or unlawful actions. The former ED was employed at the facility from 01/2024 through 02/2026.

Interview on 03/26/26 at 1:31 P.M. with CP #232 stated that CP #222 had shoved a police officer at her home. CP #232 stated that CP #222 was talking to lawyers since she went to jail last fall. CP #232 stated if she was arrested or had charges, she would have notified her manager right away.

Interview on 03/26/26 at 1:45 P.M. Cook #260 stated that CP #222 had assaulted a police officer and was arrested around November 2025. Cook #260 said he would notify the management right away if he had been arrested or had unlawful actions.

Interview on 03/26/26 at 2:13 P.M. with Dinning Services Coordinator (DSC) #256 stated CP #222 told her she had assaulted a police officer. DSC #256 stated that CP #222 was vocal about her personal life. DSC #256 stated that it was an employee's job to notify management of arrests or charges.

Interview on 03/26/26 at 2:27 P.M. with Licensed Practical Nurse (LPN) #228 who stated CP #222 would tell her about her going to court and assaulting a police officer. LPN #228 stated if she had been arrested, she would tell the human resources, Wellness Director, and Executive Director as soon as possible.

A telephone interview on 03/26/26 at 3:30 P.M. with CP #222 stated her current husband had beat her last year August 2025. CP #222 stated the police and child protective services came to her home August 2025 last year. CP #222 stated she was at her mother's home when they came to remove all my children because of the domestic violence that my husband had caused. CP #222 stated he tried to strangle me to death last year. CP #222 stated that after child protective services took my kids, the police had heard me make a statement that I had no reason to live since my children was taken away. CP #222 stated she shut her front door, but the police officer beat her door down to get to her. CP #222 stated the police officer came into her house and tackled her. CP #222 stated she went to the hospital and was never arrested. She was released after being evaluated for her death threat at emergency room. CP #222 stated she went home that day and was never arrested. CP #222 stated she had to go get fingerprints and picture because she goes to court in May 2026. The police department was trying to press charges for assaulting a police officer. The police chief had called me to apologize later after reviewing the body cam. The body cam showed I was tackled by the police officer at the house.

A telephone interview on 03/27/26 at 11:13 A.M. with Police Administrative Assistant (PAA) #268 who stated CP #222 did get arrested for an incident on 08/20/25. PAA #268 stated that children services went to CP #222 house to take away the children because CP #222 would not press charges against her husband who was abusive. PAA #268 stated that children services showed up with the police to take the kids. PAA #268 stated that CP #222 made some statements that caused the kids to cry. CP #222 stated her kid would die because he had an ear infection, and pneumonia, if they took him away. CP #222 stated when the kids were taken, the police officer heard CP #222 make a comment that she had nothing to live for now. PAA #268 stated CP #222 tried to shut the door in the police officers face, and the police officer placed his foot in the door so it would not close. PAA #268 stated the police officer walked into the house to ask CP #222 again to come with him because she needed to go to the hospital to be evaluated. PAA #268 stated that he went to reach for her to ask her again to come with him, CP #222 pulled away and swung her arm away. CP #222 fell on the floor moving away, and police officer asked her again to go to the hospital to be evaluated. CP #222 while on the floor started kicking and hitting the police officer and resisting. PAA #268 stated that the police officer pink slipped her to go to the hospital for her safety since she made the death threats. PAA #268 stated at this time CP #222 had a pretrial date scheduled on 04/22/26. CP #222 trial date for hitting a police officer was set for 05/04/26. PAA #268 stated the police chief had never called CP #222 to apologize for the police officer who arrested her. PAA #268 stated that the police officer never beat down CP #222 door at her home. PAA #268 stated that CP #222 had fingerprints and mug shot pictures, because she was arrested. PAA #268 stated that CP #222 had to come to the police station to have it done, since she went to the hospital on 08/20/25. The body cam verified the officers' account of the incident.

During a follow-up telephone interview on 03/27/26 at 11:39 A.M. with Executive Director who stated when the facility hired CP #222 on 09/15/25, her background check came back clean. She had no marks to prevent her from hire on any of the registries. Executive Director stated the facility knew nothing about an arrest. Executive Director verified that CP #222 was suspended and had not worked since 03/23/26.

This violation represents non-compliance investigated under Complaint Number OH00169921.

Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure the abuse policy was followed when the facility did not take action to ensure residents were protected following an allegation of abuse. This affected one (#49) of four residents reviewed for abuse. The facility census was 50.

Findings include:

Review of the medical record for Resident #49 revealed the resident was admitted to facility on 01/24/20. Diagnoses included Alzheimer's disease, anxiety, dementia, and chronic renal failure.

Review of the functional assessment for Resident #49 completed 08/12/20 revealed the resident was assessed to require daily orientation assistance and assist with all care.

Review of the nursing progress notes dated 12/06/25 at 9:15 P.M. revealed Resident #49 told her care giver she was afraid she was pregnant. The resident was noted to be viably upset. At 9:45 P.M., the resident again was upset. The resident stated she was afraid the man who put her to bed got her pregnant and the caregiver told the nurse. Further review revealed Resident #49 was not assessed, the police were not called, and the physician was not informed of the allegation.

Observation and interview of Resident #49 on 12/17/25 at 10:00 A.M. revealed the resident was well groomed and the resident was talkative. The resident could not recall the incident.

Interview with Corporate Nurse (CN) #42 on 12/17/25 at 10:20 A.M. confirmed Resident #49 was involved in an abuse allegation. CN #42 stated the male care giver Resident #49 was fearful got her pregnant on 12/06/25 was allowed to finish his shift after report of the allegation, but was not to go into the resident's room. CN #42 stated an additional care giver working with the male care giver went to lunch and did not return to the facility, leaving the male care giver alone with the residents, including Resident #49. CN #42 confirmed the charge nurse failed to assess Resident #49 following the allegation and did not assess any other residents on the memory care unit. CN #42 stated the male care giver was not removed from the facility and the physician nor the police were contacted until 12/10/25. CN #42 also stated Resident #49 was sent to the hospital for evaluation on 12/10/25, four days after the alleged incident. CN #42 confirmed the facility did not follow the facility abuse policy related to the incident involving Resident #49 on 12/06/25.

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

Based on closed medical record review and staff interview, the facility failed to ensure medication was administered per physician order. This affected one (#10) of three residents reviewed for medication administration. The facility census was 51.

Findings include:

Review of the closed medical record for Resident #10 revealed an admission date of 04/14/25, with diagnoses including congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus Type II and anxiety. The resident was discharged on 6/12/25.

Review of a physician order dated 05/13/25 revealed Resident #10 was ordered hydralazine (used to treat heart failure) 25 milligrams (mg) two times daily. Further review of the order revealed to hold for a systolic blood pressure (SBP) of less than 120 millimeters of mercury (mm/hg).

Review of the May 2025 and June 2025 Medication Administration Record (MAR) revealed hydralazine was scheduled to be administered to Resident #10 twice daily at 9:00 A.M. and 9:00 P.M., with a section to document the resident's blood pressure (BP) and a section to document if the medication was administered. Review of the 9:00 A.M. dose administration revealed on 05/15/25, NA was documented for the resident's BP, and the medication was administered; on 05/21/25, the resident's BP was 118 (systolic) over (/) 64 (diastolic), and the medication was administered; on 05/28/25, the resident's BP was 118/70, and the medication was administered; and on 06/10/25, the resident's BP was 107/60, and the medication was administered. Further review of the 9:00 P.M. dose administration revealed on 05/22/25, Resident #10's BP was 116/62, and the medication was administered, and on 05/29/25, the resident's BP was 119/63, and the medication was administered.

Interview on 07/10/25 at 3:35 P.M. with Wellness Director (WD) #102 verified Resident #10's hydralazine was administered outside of the physician ordered parameters on 05/21/25, 05/22/25, 05/28/25, 05/29/25 and 06/10/25. Further interview confirmed there was no evidence Resident #10's BP was checked on 05/15/25, prior to the administration of hydralazine, to verify the administration met the physician order parameters.

This violation represents non-compliance investigated under Complaint Number OH00167027.

Based on closed medical record review, review of physician orders and staff interview, the facility failed to ensure therapeutic diets were implemented per physician order. This affected one (#10) of three residents reviewed for diet orders. The facility census was 51.

Findings include:

Review of the closed medical record for Resident #10 revealed an admission date of 04/14/25, with diagnoses including congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus Type II and anxiety. The resident was discharged on 6/12/25.

Review of a physician order dated 06/07/25 revealed Resident #10 was ordered a two gram (gm) sodium diet with no added salt.

Review of the physician orders located in Resident #10's electronic medical record (EMR) revealed a regular diet was ordered on 04/12/25. Further review revealed no evidence the EMR physician orders were updated with the new order for a two gm sodium diet with no added salt on 06/07/25.

Interview on 07/10/25 at 3:35 P.M. with Wellness Director (WD) #102 verified Resident #10's diet order was changed on 06/07/25, the order was never entered into the EMR and, therefore, was not implemented.

This violation represents non-compliance investigated under Complaint Number OH00167027.

Based on observation and staff interview, the facility failed to ensure proper ice scoop storage on the memory care unit to prevent contamination. This had the potential to affect all 22 (#11, #13, #14, #15, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, and #37) residents residing on the Memory Care Unit (MCU). The facility census was 51.

Findings include:

Observation on 07/10/25 at 10:45 A.M. of the MCU revealed the ice scoop was directly on the counter, to the side of the ice machine. A crumpled dish towel was next to the ice scoop.

Continued observation on 07/10/25 at 11:12 A.M. of the MCU revealed Dietary Aid (DA) #111 picked up the ice scoop from the counter and used it to scoop ice from the ice machine and into steel bowls.

Interview on 07/10/25 at 11:15 A.M. with DA #111 verified the ice scoop had been laying directly on the counter when she picked it up and used it to scoop ice from the ice machine and into bowls. DA #111 confirmed there was no holder for the ice scoop to ensure sanitary storage.

Interview on 07/10/25 at 11:16 A.M. with Care Partner (CP) #112, who routinely worked on the MCU, verified there was no container for the ice scoop like up front, so it was stored directly on the counter beside the ice machine.

Interview on 07/10/25 at 3:35 P.M. with the Administrator revealed he was not previously aware the MCU did not have a proper storage container for the ice scoop. He acknowledged it was a concern to leave to scoop uncovered on the counter.

This violation represents non-compliance investigated under Complaint Number OH00166274.

Based on closed medical record review and staff interview, the facility failed to ensure the monitoring results of a resident's conditions were reported to the physician, as ordered. This affected one (#10) of three residents reviewed for medication administration. The facility census was 51.

Findings include:

Review of the closed medical record for Resident #10 revealed an admission date of 04/14/25, with diagnoses including congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus Type II and anxiety. The resident was discharged on 6/12/25.

Review of Resident #10's physician orders revealed an order dated 05/10/25 for daily blood pressure (BP) and to notify the clinic (physician) if the resident's systolic blood pressure (SBP - top number in a BP reading) was less than 110.

Review of the May 2025 and June 2025 Medication Administration Record (MAR) revealed Resident #10 had documented BPs of 104 (systolic) over (/) 62 (diastolic) millimeters of mercury (mmHg) on 05/26/25, 101/57 on 06/05/25 and 107/60 on 06/07/25.

Review of Resident #10's medical record revealed no evidence the physician was notified of the resident's BP on 05/26/25, 06/05/25 or 06/07/25, as ordered.

Additional review of Resident #10's physician orders revealed an order dated 05/10/25 to weigh the resident daily and to notify the physician if there was a change in weight of two pounds (lbs) in one day or five lbs in a week.

Review of the May 2025 and June 2025 Treatment Administration Record (TAR) revealed Resident #10 had a documented weight of 174.3 lbs and 178 lbs (a 3.7 lbs increase), both on 05/30/25. On 06/09/25, Resident #10's weight was 173.4 lbs and on 06/10/25 it was 176 lbs (a 2.6 lbs increase).

Review of Resident #10's medical record revealed no evidence the physician was notified of Resident #10's weight gain of more than two lbs on 05/30/25 or 06/10/25.

Further review of Resident #10's physician orders revealed an order dated 05/14/25 to measure Resident #10's leg circumference three times weekly (Monday, Wednesday, and Friday), and notify the clinic of swelling or increase in size.

Review of the May 2025 and June 2025 TAR revealed a documented measurements on 05/26/25 of the left leg of 15.75 inches, and the right leg was 15.75 inches. On 05/28/25 the left leg increased to 16.5 inches and the right leg increased to 17 inches. On 06/09/25 the left leg circumference was 16 inches and the right leg was 15.75 inches. On 06/11/25 the left leg increased to 16.5 inches and the right leg increased to 17 inches.

Review of Resident #10's medical record revealed no evidence the physician was notified of Resident #10's increased leg circumference on 05/28/25 or 06/11/25, as ordered.

Interview on 07/10/25 at 3:35 P.M. with Wellness Director (WD) #102 verified the facility had no evidence of physician notification for Resident #10's BP results on 05/26/25, 06/05/25 or 06/07/25, of the resident's weight gain of greater than two lbs on 05/30/25 and 06/10/25, or the resident's increased leg circumference on 05/28/25 and 06/11/25.

This violation represents non-compliance investigated under Complaint Number OH00167027.

Based on observation, staff interviews, and review of facility policy, the facility failed to ensure food was stored, prepared and served in a manner protecting it from potential contamination and spoilage. Additionally, the facility failed to ensure the dishwasher was reaching the appropriate temperature to sanitize the dishes. This had the potential to affect all 28 residents residing in the facility. The facility census was 28.

Findings include:

1. Observation on 04/14/25 between 8:36 A.M. and 9:20 A.M. in the front kitchen revealed Cook #5 was not wearing a hair net while plating and serving breakfast. Observation of reach in freezer located in the kitchen area at 8:40 A.M. showed four cups of ice cream and two cups of sherbet in the freezer with no date and no covering. There was a grey cart noted sitting against the wall with three large reusable bins on top. Bins were labeled Sugar, Flour, Flour. There are no open or expiration dates on the bins.

Observation of the walk-in fridge on 04/14/25 at 8:50 A.M. revealed a box of hamburgers, a box of bulk bacon and a box of pork chops. All boxes noted to be open with contents no longer frozen. All boxes labeled Keep frozen. There was no date noted as to when the burgers were thawed in the fridge.

Observation of the walk-in freezer on 04/14/25 at 8:52 A.M. revealed two bags labeled Beef Empanadas, which appeared to be freezer burned with no expiration date on the bags, and one open bag of Pretzels which also appeared to be freezer burned with no expiration date or no open date.

Observation on 04/14/25 at 9:00 A.M., of the dry storage area was revealed a covered reusable container of white beans with no open or expiration date.

Interview with Cook #5 during the kitchen observation on 04/14/25 between 8:36 A.M. and 9:20 A.M. confirmed the observations in the kitchen.

2. Observation of the back kitchen on 04/14/25 at 9:35 A.M. noted Cook #6 was not wearing a hair net in the kitchen. The reach in fridge was noted two extra large bottles of Catalina (salad) dressing open with no open date on them; one large bottle of ranch dressing, opened with no open date on it; box containing half of a remaining cake with no open date; open bottle of Chocolate Topping with no open date; and a container filled with single use whipped spread butter with no expiration date.

Interview with Cook #6 on 04/14/25 at 9:35 A.M. confirmed the observation with the facilities back kitchen.

3. Observations on 04/14/25 at 9:40 A.M., revealed the dishwashing machine in the back kitchen wash cycle temperature was recorded at 150 degrees Fahrenheit (F), and the rinse cycle temperature was recorded at 175 degrees F. Observations of the sticker on the side of the dishwashing machine stated that the wash cycle should be a minimum of 150 degrees F and the rinse cycle should be a minimum of 180 degrees F. Cook #6 confirmed the dishwasher was not reaching the appropriate temperature to sanitize the dishes.

Review of the facility policy titled Food Storage last revised 06/24, revealed all foods must be stored in a manner that maximizes nutrient retention, quality, and food safety.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure that hazardous cleaning chemicals were stored securely and labeled appropriately. This had the potential to affect all 28 residents residing in the facility. The facility census was 28.

Findings include:

Observation on 04/14/25 at 9:25 A.M., a backpack sprayer containing an unlabeled blue liquid was observed in the unlocked laundry room. The container was not secured, labeled, or stored in an secure manner. Director of Nursing (DON) #4 confirmed the presence of the sprayer and stated that the liquid was a multipurpose disinfectant. DON #4 also confirmed all chemicals should be appropriately label so they can be identified.

On 04/14/25 at 10:05 A.M., a container labeled Peroxide Multi-Surface Cleaner and Disinfectant was observed stored in a lower cabinet within the front kitchenette, an area where food preparation and serving occur. The container was not stored in a designated chemical storage space and was accessible within an area used for food handling and an area accessible by residents. At the time of observation, Transporter #1 confirmed the presence of the chemical in the cabinet.

Review of facility policy titled Storage of Chemicals and Toxic Materials last revised on 08/24 revealed all chemicals and other toxic materials must be stored appropriately away from food/food preparation/food storage areas in order to maintain the health and safety of residents and associates. The policy further clarifies all chemicals and toxic materials must have an occupational safety and health administration approved label.