Brookdale Piqua

Based on record review, observations and staff interviews, the facility failed to ensure medications were administered timely, documented appropriately and the physician was updated on repeated medication refusals. This affected two (#10 and #12) of five residents reviewed for medication administration. Facility census was 30.

Findings include:

1. Record review of Resident #10 revealed an admission date of 12/02/24 with diagnosis of congestive heart failure, depression, anxiety and atherosclerotic heart disease.

Review of the 12/03/24 Personal Service Plan revealed Resident #10 was on hospice, did not get out of bed and required staff assistance for Activities of Daily Living.

Observation on 01/13/25 at 9:40 A.M. with Licensed Practical Nurse (LPN) #13 of the medication pass for Resident #10 revealed upon preparation to prepare requested pain medication, Oxycodone Immediate Release, the narcotic sheet order was for one, half tablet. The two previous entries documented two, half tablets as given. LPN #13 looked in the electronic record and stated the it had not been changed, but he would clarify the order.

Interview on 01/13/25 at 10:10 A.M. with Wellness Director #50 revealed there had been a telephone order on 01/12/25 at 10:25 A.M. to increase the Oxycodone Immediate Release (Oxy IR) to give two, half tablets to equal five milligrams (mg).

Interview on 01/15/25 at 1:30 P.M. with Wellness Director #50 acknowledged the 01/12/25 order increase of Oxy IR from 2.5 mg to 5.0 mg had not been updated in the electronic orders and verified the electronic Medication Administration Record did not reflect the actual Oxy IR dose given. Wellness Director #50 verified the current pharmacy used and shared medication changes were not always updated into the electronic orders, and in turn the electronic MAR timely.

Further review of Resident #10's medical record revealed an order change on 01/12/25 to increase the Oxy IR from 2.5 mg to 5.0 mg every four hours as needed for pain. Review of the fax confirmation to the pharmacy revealed it was accepted on 01/12/25 at 8:48 P.M.

Review of the narcotic sheet for Resident #10 revealed she received two, 2.5 mg tablets of Oxy IR on 01/12/25 at 7:48 P.M., on 01/13/25 at 12:43 A.M., 10:16 A.M., on 01/14/25 at 4:03 A.M., 8:40 A.M., 1:20 P.M., 11:21 P.M. and on 01/15/25 at 5:40 A.M.

Review of the Medication Administration Record (MAR) revealed the order change for the Oxy IR had not been entered into the system. Documentation indicated one 2.5 mg Oxy IR tablet had been given on 01/12/25 at 7:48 P.M., on 01/13/25 at 12:43 A.M. and 10:16 A.M., and on 01/14/25 at 4:03 A.M., There was no documentation for 8:40 A.M., 1:20 P.M., 11:21 P.M. or on 01/15/25 at 5:40 A.M. on the electronic MAR.

2. Record review for Resident #12 revealed an admission date of 12/09/20. Diagnosis include hypothyroidism.

Review of the 07/24/24 personal Service plan revealed she required supervision for meal, mechanical lift for transfers and staff assistance for all other Activities of Daily Living.

A review of the progress notes dated 10/25/25 at 11:40 P. M revealed an order to discontinue artificial tear eye drops four times daily due to resident refusal and causing distress.

A review of Resident #12's October 2024 MAR revealed the artificial tears was not discontinued in the electronic orders until 10/28/24. The medication was not discontinued from the electronic MAR until 10/28/24 at 5:19 AM. The artificial tears was documented as given on 10/26/24 and 10/27/24 at 12:00 PM and refused at 5:00 A.M., 4:00 P.M. and 8:00 P.M.

Review of the physician orders for Resident #12 revealed an order for levothyroxine (thyroid) 25 micrograms daily scheduled at 5:00 A.M.

Review of the October 2024 MAR revealed Resident #12 refused Levothyroxine 24 of 30 days. Review of the November 2024 MAR revealed she refused the Levothyroxine 19 of 29 days. Review of the December 2024 MAR revealed a time change for the Levothyroxine from 5:00 A.M. on 12/02/24 to 8:00 A.M. There were no further refusals in December.

Further record review revealed no documentation Resident #12's physician had been contacted regarding multiple medication refusals.

Interview on 01/15/25 at 1:30 P.M. with Wellness Director #50 verified the discontinued artificial tears were given after they had been discontinued. Wellness Director #50 also stated it would be the expectation the physician would have been updated regarding Resident #12's repeated refusals of Levothyroxine and acknowledged the time adjustment for the medication should have been done sooner.

Based on observations, staff interviews, local health department (LHD) interviews and policy review, the facility failed to ensure safe and sanitary food storage. This had the potential to affect all 30 residents residing in the facility who received meals from the kitchen. Facility census was 30.

Findings include:

Observation on 01/13/25 at 8:07 A.M. upon entrance to the facility revealed active construction was underway due to a recent water leak. The ceiling of the entry and dining area was missing, and the rafters and roof were visible. There was a clear plastic door barrier taped to the frame of the door leading from the dining room to the kitchen. The tape on the lower right corner revealed an approximate six inch by six-inch break in the barrier. The observation of the clear plastic barrier revealed there was the possibility of cross contamination of the food preparation and kitchen area.

Interview on 01/13/25 at 8:41 A.M. with Wellness Director #50 and Executive Director revealed the local health department had not been contacted for inspection of the kitchen following a recent water leak resulting in water damage at the facility. The facility confirmed all 30 residents residing in the facility receive their meals from the kitchen.

Observation on 01/13/25 at 9:17 A.M. in the kitchen revealed there was a clear plastic unclosed bag containing ten unmarked, undated meat patties; what appeared to be ham covered in ice crystals was noted in an undated, unsealed zip lock bag; unlabeled, undated meat in a clear sealed bag and an unlabeled, undated Styrofoam container containing three slices of cooked bacon. Cook #10 verified the food items at the time of the observation.

Observation on 01/13/25 at 11:25 A.M. revealed an approximately five inch by twelve-inch area of a white powdery substance on the floor just inside the dining room door against the wall of the kitchen. This was verified by Kitchen Manager #11 to be a result of the flooding into the kitchen.

Interview on 01/13/25 at 12:47 with LHD Environmental Health Specialist (LHD EHS) #12 revealed she had been contacted by the facility on this date regarding the facility being under construction related to a recent water leak resulting in water damage. LHD EHS #12 advised she had a concern with the plastic door barrier being used in the kitchen, as well as with the ongoing construction to the adjoining kitchen/dining wall.

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, food safety and should be maintained free from dirt, dust and any potential sources of contamination.

Based on observations, staff interviews review of survey documents provided by the facility, the facility failed to ensure the State Fire Marshall was contacted timely after a disruption with the facility fire sprinkler system. This had the potential to affect all 30 residents residing in the facility. Facility census was 30.

Findings include:

Observation on 01/13/25 at 8:07 A.M. upon entrance to the facility revealed active construction was underway related to a recent water leak resulting in water damage to the facility. The ceiling of the entry and dining area was missing, and the rafters and roof were visible.

Interview on 01/13/25 at 8:41 A.M. with the Executive Director (ED) revealed a contractor had stepped on the fire sprinkler line on 01/08/25 causing it to break and flood the area directly below. One resident room was affected and the resident was relocated to another room temporarily. The wet sprinkler system was working at the time of the interview. A second interview with the ED on 01/13/25 at 2:32 P.M. revealed the disruption in the sprinkler system automatically notified the fire department and they did come to the facility. The ED shared it took one and a half days for the wet sprinkler system to be repaired. The ED verified the State Fire Marshall had not been notified the sprinkler system had been inoperable.

Review of survey documentation provided by the facility revealed the staff documented a fire watch in the facility starting on 01/08/25 after a water leak with the fire sprinkler system. There was no documentation the State Fire Marshall had been notified of the incident or that the sprinkler system had been inoperable.

Based on review of fire drills and staff interviews, the facility failed to ensure fire drills were completed on each shift every three months. This had the potential to affect all 30 residents residing in the facility. Facility census was 30.

Findings include:

Review of the monthly fire drills revealed one fire drill was performed on third shift on 09/28/24. Further review of the fire drills revealed there was no other documentation a fire drill being performed on third shift in the past 12 months or in 2024.

Interview on 01/15/25 at 11:57 P.M. with Maintenance Manager #20 verified the facility only conducted one fire drill on the third shift in the past 12 months or in 2024 and this was on 09/28/24.