Brookdale Greenville

Based on review of personnel files and staff interview, the facility failed to ensure care partners (CP) were trained in providing personal care services to residents. This affected two (#100 and #150) of four personnel files reviewed. This had the potential to affect all the residents of the facilty. The facility census was 35.

Findings include:

1. Review of CP #100's personnel file revealed a hire date of 05/12/26. Further review revealed no documentation of CP #100 being trained to provide personal care services. CP #100 was not a certified nurse aide (CNA).

2. Review of CP #150's personnel file revealed a hire date of 05/01/26. Further review revealed no documentation of CP #150 being trained to provide personal care services. CP #150 was not a CNA.

Interview with the Administrator on 06/03/26 at 11:11 A.M. confirmed CP #100 and CP #150 had not been trained in personal care services and were working independently in the facility.

This violation represents non-compliance investigated under Complaint Number OH00170666.

Based on medical record review, review of the facility incident log, staff interview and review of facility policy, the facility failed to document a resident's falls on the facility incident Log. This affected one (#41) of four residents reviewed for falls. The facility census was 35.

Findings include:

Review of Resident #41's closed medical record revealed an admission date of 04/25/25. Diagnoses listed included glaucoma, hypertension, and Alzheimer's disease. Resident #41 was discharged from the facility on 05/28/26.

Review of progress notes dated 04/27/26 at 6:24 P.M. revealed Resident #41 had a fall near a dining room table. Review of progress notes dated 04/28/26 at 7:25 A.M. revealed resident care aides (RCA) reported to the nurse that Resident #41 had fallen from his bed during the night and was transferred to a local hospital for treatment and had returned to the facility.

Review of the facility incident log revealed no falls for 04/27/26 or 04/28/26 were listed for Resident #41.

Interview with the Administrator on 06/03/26 at 11:11 A.M. confirmed Resident #41 falls on 04/27/26 and 04/28/26 were not listed on the facility incident log. The Administrator stated resident falls are entered into the facility's accident and incident reporting system which provides details on the facility incident log.

Review of the facility's policy titled Falls Management and Recovery Policy dated October 2013 revealed resident falls are noted in the resident record and entered into the facility's accident and incident reporting system.

This violation represents non-compliance investigated under Complaint Number OH00170666.

Based on observation, staff interview and review of the facility policy, the facility failed to ensure foods were properly stored and further failed to ensure the kitchen and equipment was maintained in a sanitary manner. This had the potential to affect all 53 residents of the facility. The facility census was 53.

Findings include:

Observation on 04/22/25 at 8:24 A.M. of the walk-in refrigerator revealed two containers, one appeared to be cherry topping and the other blueberry topping, which were unlabeled and undated; an undated bag of whipped topping with the open end uncovered and exposed to the air; an open, undated package of diced ham; an open, undated package of sliced ham; and an open, undated package of hot dogs. Additional observations revealed a shelf with defrosting meats that had an unknown black growth on the front of the shelf.

Observation on 04/22/25 at 8:28 A.M. of the walk-in freezer revealed a bag of open, undated bag of frozen apples. Further observation revealed several boxes on the floor, including an open box of sheet cakes, a box of beef, and a Styrofoam container with ice cream.

Interview on 04/22/25 at 8:30 A.M. with Lead Cook (LC) #52 verified the findings in the walk-in refrigerator and walk-in freezer.

Observation on 04/22/25 at 8:46 A.M. of the reach-in freezer revealed an open, undated bag of chicken tenders, an open, undated bag of breaded fish and an open, undated bag of French fries. Concurrent interview with LC #52 verified the findings.

Observation on 04/22/25 at 8:48 A.M. of the deep fryer revealed the oil was black in color and had food particles along the sides and in the oil. Concurrent interview with LC #52 verified the findings, adding the oil was last changed in March 2025.

Observation on 04/22/25 at 8:53 A.M. of the dietary dry stock storage room revealed a box of mandarin oranges on the floor, with additional boxes stacked on top of it. Further observation revealed three open, undated bags of noodles, with one of the bags of noodles unsealed and open to the air. Concurrent interview with LC #52 confirmed the findings. LC #52 further confirmed all foods should be labeled with the date they were opened to ensure quality.

Observation on 04/22/25 at 8:55 A.M. of the air conditioner units located in the dishwasher room and the main kitchen area revealed a black growth on the vents of both units. Concurrent interview with LC #52 verified the findings and stated maintenance was responsible for cleaning the air conditioner units.

Review of the facility policy titled, Food Storage, revised June 2024, revealed that storerooms and walk-ins should be maintained free from dirt, dust, insects, rodents or any potential sources of contamination and all foods should be stored on storeroom shelving that is no less than six inches from the floor.

Based on observation, staff interview, hospice staff interview, medical record review, and review of the facility policy, the facility failed to ensure residents were protected from the use of physical restraints to limit mobility. This affected one (#11) of one resident review for restraints. The facility census was 53.

Findings include:

Review of Resident #11's medical record revealed an admission date of 03/28/23. Diagnoses included malignant neoplasm of the left bronchus and vascular parkinsonism. Further review revealed Resident #11 received hospice services and had a risk agreement for the use of a Halo bed rail to assist with repositioning and transfers from bed.

Observation on 04/22/25 at 10:11 A.M. revealed Resident #11 was in the common area, adjacent to the dining room. Resident #11 was sitting in a Geri chair (reclining, wheeled chair), which was leaned back to an approximately 45 degree angle, with the footrests also extended to approximately 45 degrees. Continuous observation through 10:17 A.M. revealed Resident #11 attempted to pull himself up four times. No staff were observed in the area at this time.

Interview on 04/22/25 at 10:17 A.M. with Hospice Aide (HA) #54 confirmed Resident #11 was leaned back in the Geri chair, restricting his ability to move freely and stand up. HA #54 stated the resident had multiple falls and the chair was leaned back to keep him from standing up without staff.

Continuous observation on 04/22/25 from 1:00 P.M. through 1:27 P.M. revealed Resident #11 was in the dining room, seated in the Geri chair that was pushed up to the table. The wheels of the Geri chair were locked. Continued observation revealed Resident #11 attempted to push the chair back and attempted to stand up against the table. Resident #11 was observed attempting to get the staff's attention prior to trying to stand. Staff approached Resident #11 and unlocked the wheels of the Geri chair. Resident again attempted to stand up. Care Giver (CG) #55 assisted Resident #11 to sit down in the Geri chair, proceeded to assist Resident #11 back to the common area adjacent to the dining room, and leaned the resident's Geri chair back to an approximately 45 degree angle. Coinciding interview with CG #55 verified Resident #11's Geri chair was leaned back to prevent the resident from getting up due to safety concerns related to falls.

Interview on 04/22/25 at 5:05 P.M. with the Executive Director (ED) and Wellness Director (WD) #57 revealed that Resident #11 was a fall risk and had fallen several times in the past. The ED confirmed Resident #11 was laid back in the Geri chair to prevent him from getting up independently and potentially falling, adding the facility could not provide one-to-one staffing for the resident.

Review of the facility policy titled, Restraints Policy, revised February 2020, revealed the definition of physical restraint was any method, device, materials, or equipment that cannot be removed by the resident and/or that restricts freedom of movement. Further review revealed the use of restraints, seclusion, aversive conditioning, coercion and posey vests were prohibited.

Based on medical record reviews, staff interview, and policy reviews, the facility failed to provide appropriate care and services for residents with urinary concerns. This affected two (#33 and #45) out of the three residents reviewed for care and services. The facility census was 52.

Findings included:

1. Review of the medical record for Resident #33 revealed an admission date of 01/26/24 with medical diagnoses of dementia, vertigo, and intellectual developmental disabilities.

Review of the medical record for Resident #33 revealed a personal service plan, dated 02/17/24, which indicated Resident #33 was cognitively intact and required assistance with bathing, dressing, grooming, and incontinence cares.

Review of the medical record for Resident #33 revealed a physician fax order sheet dated 12/28/24 which stated Resident #33 complained of burning sensation while urinating. The fax sheet revealed a transmission stamp was dated 01/06/25.

Review of the medical record for Resident #33 revealed physician order dated 01/08/25 for urinalysis (UA) with culture and sensitivity (C&S).

Review of the medical record for Resident #33 revealed an order dated 01/21/25 for nitrofurantoin (Macrobid) 100 milligram (mg) one capsule two times per day for seven days.

Review of the medical record for Resident #33 revealed a nurse's note, dated 12/28/24 at 8:57 P.M., which stated resident complained of burning sensation while urinating. The note stated Resident #33 was encouraged to increase by mouth fluids and the primary care physician (PCP) was faxed. Further review of the medical record revealed a nurse's note, dated 01/08/25 at 4:11 P.M., which stated the facility received an order for a UA with C&S to be scheduled on the next lab day. Review of a nurse's note dated 01/17/25 at 1:21 P.M. stated the final UA with C&S results were faxed to PCP's office and the office was called and informed the UA results were faxed. Review of a nurses' note dated 01/20/25 at 5:11 P.M. stated PCP office called to update and provided an order for Macrobid 100 mg capsule by mouth two times per day for seven days for urinary tract infection.

Review of the medical record for Resident #33 revealed a UA with C&S results, dated 01/14/25, which indicated Escherichia coli 16,000-20,000 and mixed flora with turbid clarity. The results revealed a handwritten note which stated physician was notified on 01/17/25.

2. Reviewed of medical record for Resident #45 revealed an admission date of 05/03/24 with medical diagnoses of pulmonary fibrosis, hyperlipidemia, bipolar disorder, diabetes mellitus, and hypertension.

Review of the medical record for Resident #45 revealed a personal service plan dated 12/13/24 which indicated Resident #45 was cognitively intact and was independent with all activities of daily living.

Review of the medical record for Resident #45 revealed a physician order dated 06/20/24 for a urology referral.

Review of the medical record for Resident #45 revealed a nurse's note, dated 06/20/24 at 2:26 P.M. which stated resident was seen by nurse practitioner who ordered labs and a referral to a urology group. The note continued to state the urology group reached out to the nurse with appointment information and transportation was arranged.

Further review of nurse's notes revealed a note dated 08/13/24 at 2:06 P.M. which stated the resident wanted to know about his urology referral that was made back in June 2024. The note stated the nurse confirmed the order was received and stated she would fax the urology group. The note continued to state the nurse notified Resident #45's guardian to schedule the initial appointment. Review of the medical record revealed a nurse's note dated 08/14/24 at 2:32 P.M. which stated Resident #45 had an appointment scheduled with a urology group on 09/03/24.

Interview on 02/21/25 at 1:01 P.M. with Director of Nursing (DON) confirmed the facility did not have documentation to support Resident #33's physician was notified timely of the complaints of burning sensation while urinating on 12/28/24. DON also confirmed the physician fax order sheet for Resident #33 had a transmission date of 01/06/25 and an order was received from the physician on 01/08/25. DON also confirmed the medical record for Resident #45 revealed an order for a urology referral on 06/20/24. DON confirmed the facility did not have documentation to support Resident #45's urology appointment was made until 08/13/24.

Review of the facility policy titled, Physician/Healthcare Provider's orders