Brookdale Kenwood

Based on observation, interview and facility policy review, the facility failed maintain a clean and sanitary environment in the kitchen and the facility failed to store, and prepare food in a sanitary manner to ensure resident safety. This had the potential to affect all residents. The facility census was 49.

Findings Include:

Observation of kitchen on 04/24/25 at 10:42 A.M. with Executive Director (ED) #18 revealed the kitchen hood and vent had grease build up and grime, the deep fryer had grease build up and grime, the microwave had debris and grime, and a sticky substance on the lid of the ice machine. Observation of the dry storage area revealed there were boxes on the saltine crackers on the ground, a box of ketchup on the ground, a soy sauce container with a sticky substance on the side of the container, a package of elbow noodles without an open date, a package of lentils with a use by date on 03/21/25, an open package of green lentils undated and unlabeled, an open box of general mills pancake mix without an open date, and an open bag of vanilla wafers without an open date. ED verified the findings at the time of the observations.

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Observation of Refrigerator two on 04/24/25 at 10:46 A.M. revealed there was an open container of minute maid orange juice without an open date, there was no thermometer present, there was liquid on the bottom shelf, and a pitcher of water, a pitcher of milk, and a pitcher of tea without an date on the pitchers. ED verified the findings at the time of the observation.

Observation of the walk-in freezer on 04/24/25 at 10:53 A.M. with ED #18 revealed there was a full frozen pie unlabeled and undated, and two Styrofoam boxes of carrot cake undated and unlabeled. ED verified the findings at the time of the observation.

Observation of the kitchen on 04/24/25 at 12:00 revealed baked chicken with a gray/greenish tint. Cook #7 made two mechanical soft portions and one pureed chicken with the baked chicken. ED #18 tempted the food showing a temperature of 112- and 130-degrees Fahrenheit for the chicken.

Interview on 04/24/25 at 12:20 P.M. with Cook #7 stated the temperature was fine and he was going to serve the chicken.

Interview on 04/24/25 at 12:22 P.M. with ED #18 verified the temperature was not at a safe serving temperature and stated the food was not an acceptable color. ED #18 instructed cook #7 to throw away the puree and mechanical soft chicken due to the temperature.

Observation of the kitchen on 04/24/25 at 12:25 P.M. revealed ED #18 placing the chicken into the oven to be cooked. ED stated she is going to bring the chicken to the correct temperature.

Observation of the kitchen 04/24/25 at approximately 12:26 P.M. revealed the chicken temperature was 140 degrees when temped by ED #18. Interview at the time of the observation with Cook #7 revealed they should serve the chicken with the 140-degrees Fahrenheit temperature because he didn't want it to be dry.

Observation of the kitchen on 04/24/25 at 12:27 P.M. ED #18 made sure the chicken remained in the oven.

Observation of the kitchen on 04/24/25 at 12:35 P.M. ED #18 pulled the chicken out of the oven and tempted the chicken. The chicken was 167 degrees Fahrenheit. The chicken appeared to be cook thoroughly and had a light brown cooked color and no green or grayish color.

Interview on 04/24/25 at 12:40 P.M. with ED #18 confirmed that the chicken was at an acceptable temperature. The executive director verified that the color of the chicken was acceptable and better than before.

Review of facility policy titled, Food Storage-DS-04/013, dated on 2005 and revised on 06/2024 states that all food should be stored on storeroom shelving,

Review of facility policy titled Labeling-DS-04/028, date on 2005 and revised on 09/2024 states that all food items must be labeled and dated before storing.

Review of facility policy titled Food and Beverage Temperature Control -Ds-04.010 dated on 2005 and revised on December 2024 stated if any temperature of food is not within an acceptable range the food needs to be reheated or discarded. The policy also states that the initial temperature for poultry should be 165 degrees Fahrenheit.

Review of facility policy titled Kitchen Cleaning dated on July 2004 states that food service equipment is to be cleaned and sanitized after every use.

This violation is a recite to the annual survey completed 07/17/24.

Based on record review, staff interview, and policy review, the facility failed to ensure a fire drill was completed on each shift every quarter for the past 12 months. The facility also failed to provide evidence of alarm transmission receipts after the drills have been completed. This had the potential to affect all 49 residents in the facility. The facility census is 49.

Findings include

1. Review of the facility Fire Drill Reports for the prior twelve months revealed fire drills were completed on 12/31/24 (first shift), 11/20/2024 (first shift), 10/31/24 (second shift), 09/30/24 (first shift), 09/16/24 (second shift), 08/16/24 (second shift), 06/27/24 (third shift), 05/30/24 (second shift), 04/30/24 (first shift), 03/31/25 (third shift), 02/28/25 (first shift), and 01/31/25 (third shift).

Interview on 04/24/25 at 5:30 P.M. with Regional Maintenance (RM) #888 verified the facility completed night shift fire drills in three of four quarters in the past 12 months. RM #888 verified the facility completed fire drills as listed on the dates listed previously.

2. Review of the Fire Drills Transmission Receipts for the facility revealed no documented evidence of fire drill alarm transmission for the following months: April 2024, May 2024, June 2024, July 2024, and August 2024.

Interview on 04/24/25 at 5:35 P.M. verified Fire Drills Transmission Receipts for the facility revealed no documented evidence of fire drill alarm transmission for the following months: April 2024, May 2024, June 2024, July 2024, and August 2024.

Review of fire policy titled, Fire Drills -SE-1 dated on 04/1997 and revised on 04/22 states fire drills should be conducted monthly with every shift participating at least once per a quarter.

Based on observation, staff interviews, and review of facility policy, the facility failed to maintain a clean and sanitary environment. This affected all residents in the facility. The facility census was 49.

Findings Include:

Observation on 04/24/25 at 10:01 A.M. of the facility revealed there was a plethora of black stains on the carpet and ripped wallpaper throughout the facility. On hall 232 -239 revealed a giant red stain on the floor at the end of the hall, on hall 220-221 revealed a medium size red stain on the corner on the floor at the edge of the left side by 220, Resident Room #24 had large scuff marks on the door, Resident Room #37 had missing trim on the outside of the door, on hall 232-239 revealed used gloves laying on the table. Throughout the facility there were scuff marks on all the walls. Executive Director #18 verified the findings in an interview on 04/24/25 at 10:30 A.M.

Review of facility policy titled, Common Area Cleaning dated on May 2019 states they should assess the area and tidy the areas.

This violation is a recite to the annual survey completed 07/17/24.

Based on observation, staff interview, and record review, the facility failed to store, prepare, and serve food in a manner a safe and sanitary manner. This had the potential to affect all residents at the facility. The facility census was 47.

Findings include:

Observation of the kitchen during the initial tour on 07/11/24 at 10:15 A.M. with the Dietary Manager (DM) # 300, revealed the following:

a) The trash can near the handwashing sink contained no liner, had dried food debris and splatter running down the sides of the trash can.

b) The Memory Care food cart had dried food splattered and debris along the sides of the cart.

c) The reach in fridge had sticky food substance along the inside of the door and dried food splattered down the sides. ) Inside the walk-in fridge contained a large, round bowl not labeled or dated with egg salad and a metal tray of eleven dessert dishes not covered or labeled contained which contained pudding.

e) There was dried splattered food debris on top of the dishwasher and on the support beams around the dishwasher .

f) Observation of the food temperature logs revealed no documented evidence the facility checked food temperatures on breakfast on 07/10/24, lunch 07/11/24, no temperatures for breakfast, lunch and dinner on 07/13/24, 07/14/24 and 07/15/24.

DM #300 confirmed the conditions of the kitchen DM #300 stated the facility staff were required to obtain temperatures of the food prior to the start of the tray lines.

Observation of the lunch tray line on 07/15/24 at 11:45 A.M., revealed Dietary Cook (DC) #133 identified a bowl sitting on the counter as cold pasta salad. DC #133 took the temperature of the cold pasta salad, and it was 77 degrees Fahrenheit (F). DM #300 placed the bowl of pasta salad in another bowl of ice and placed them both in the refrigerator. DC #133 identified a bowl of cold cucumber salad and obtained a temperature which was 66 degrees F. DM #300 and DC #133 started the tray line for the Memory Care Unit. DC #133 took the large metal bowl of pasta salad out of refrigerator and rechecked the temperature and it was 44 degrees F. DC #133 plated the cold pasta salad and placed trays on the Memory Care Unit cart. The Memory Care Unit cart was delivered to the unit at 12:30 P.M. and all trays were delivered to the residents at 12:39 P.M.

Observation of the test tray on 07/17/24 at 12:42 P.M., with DM #300 revealed the pasta salad was not cold. DM #300 verified the cold pasta salad had a temperature of 77 degrees F and it was placed back in the refrigerator.

Interview with the Registered Dietician (RD) #201 on 07/15/24 at 1:58 P.M. revealed the staff should not have served the cold pasta salad once the temperature was measured at temperature at 77 degrees F because it reached the danger zone temperature. RD #201 stated the facility should have thrown out the pasta salad.

Review of the facility policy titled, Food and Beverage Temperature Control, dated 02/2024, revealed to ensure the safety of residents and associates, all potentially hazardous food and beverages will be maintained at a safe and appetizing temperature. The policy stated the staff should utilize the food temperature log to ensure all food and beverages are monitored.

This violation represents non-compliance investigated under Complaint Number OH00150485.

Based on observation, staff and resident interviews, and review of facility policy, the facility failed to maintain a clean and sanitary environment. This affected two (#32 and #44) residents of the two residents reviewed. The facility census was 47.

Findings included:

Review of the medical record for Resident #32 revealed the resident was admitted to the facility on 11/30/23. Diagnoses included Parkinson's disease, ulcerative colitis, anemia, hyperlipidemia, and essential primary hypertension.

Review of Resident # 32' s most recent Physical Assessment dated 12/01/23, revealed the resident was cognitively impaired and dependent on staff activities of daily living (ADLs).

Review of the medical record for Resident #44 revealed the resident was admitted to the facility on 09/25/23. Diagnoses included hyperlipidemia, major depressive disorder, anxiety disorder, and cerebral infarction.

Review of Resident #44's Personal Service Assessment dated 09/25/23 revealed she was dependent on staff for medication administration, bathing, and toileting. Resident #44 required assistance from staff for sit up for eating.

Interview with Resident Care Associate (RCA) #107 on 07/11/24 at 10:58 A.M., revealed she started her shift at 7:00 A.M. and entered Resident #32's room with Licensed Practical Nurse (LPN) # 90. RCA #107 stated Resident #32 had feces all over him and his bed. RCA #107 stated that LPN #90 asked her to take a picture so they could show it to the Health and Wellness Director (HWD) #500.

Observation of Resident #44's room on 07/11/24 at 11:10 A.M., revealed the apartment had soiled and stained carpets in her living room and bedroom areas with debris scattered throughout the carpet.

Interview with RCA #44 on 07/11/24 at 11:15 A.M., verified the heavily soiled and stained carpets with debris scattered throughout the bedroom and living room.

Observation of Residents #32 and #33's apartment on 07/11/24 at 11:25 A.M. revealed yellowish/ brown stains and debris all over the carpet in the living room and the bedroom.

There were soiled sheets rolled up and laying on Resident #32's bed, and pillow with a yellowish/brown discoloration lying in the shower and a gray bucket in the middle of the bathroom floor with soiled incontinent briefs, soiled wipes and gloves. Resident #33 stated the rolled up soiled sheets on Resident #32's bed were there because the resident had a large bowel movement between 5:00 A.M. and 6:00 A.M. and when the staff cleaned the resident, they left the sheets on the bed and put the soiled pillow in the shower.

Interview with LPN #90 on 07/11/24 at 11:37 A.M., revealed he and RCA #107 entered Resident #32's room that morning and found Resident #32 with feces all over him, the bed sheets, and the pillow and LPN #90 asked RCA#107 to take pictures of the soiled items. LPN #90 confirmed the soiled sheets remained in a ball on Resident #32's bed, and the soiled pillow was in the shower, and the bucket with soiled incontinent briefs, gloves, and soiled wipes remained in the middle of Resident #32's bathroom floor. LPN #90 confirmed the resident's apartment had large yellowish/brown stains and debris throughout the carpet in the bedroom and living room.

Review of the facility policy titled, Infection Control Plan, dated 05/2023, confirmed regulated waste should be put in a well-constructed container with a secure lid to prevent leaking.

This violation represents non-compliance investigated under Complaint Number OH00150485.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff transferred residents from wheelchair to commode per acceptable and safe standards of practice. This affected one (#34) of three residents reviewed for falls. The facility census was 38.

Findings include:

Review of the medical record for Resident #34 revealed an admission date of 11/21/18 with diagnoses including spinal stenosis, hypertension (HTN), anxiety disorder radiculopathy, presence of artificial knee joint, osteoporosis, and major depressive disorder.

Review of the service plan for Resident #34 dated 05/05/21 revealed the resident was at risk for falls. Interventions included to provide education on waiting for the community staff to assist with transfers, re-education on importance of proper footwear during transfers, re-education to ask for assistance for transfers, may utilize sit to stand lift with assistance of two staff for transfers during periods of increased weakness, and follow safe handling practices.

Review of the personal service assessment for Resident #34 dated 01/27/23, under the section regarding bathroom assistance, revealed the resident required staff assistance in getting onto and off the toilet and additional help with incontinence care. Further review revealed the resident was not able to stand independently while using the bathroom and required weight-bearing and balance assistance of one member of staff. Further review of the personal service assessment revealed Resident #34 sometimes required the use of a mechanical lift with transfers and the assistance of two staff and Resident #34 was cognitively intact.

Observation of toileting and incontinence care for Resident #34 on 05/22/23 at 10:45 A.M. revealed Nursing Assistant (NA) #245 provided weight bearing and stand by assistance for Resident #34 during transfer from the wheelchair to the commode and during transfer from the commode to the wheelchair. NA #245 did not utilize a gait belt while transferring the resident, but instead grabbed the back of Resident #34's waistband of the resident's pants and held onto it as NA #245 guided the resident on and off the commode.

Interview on 05/22/23 at 10:52 A.M. with NA #245 confirmed Resident #34 was at increased risk for falls due to weakness and unsteady gait. NA #245 confirmed Resident #34 required assistance of one staff member for transfers. NA #245 confirmed she did not use a gait belt because it was not required in assisted living.

Interview on 05/22/23 at 1:30 P.M. with the Director of Nursing (DON) confirmed the facility did utilize gait belts for assisting with transfers for residents at risk for falls or for any challenges with mobility or weakness. DON confirmed staff should use a gait belt when assisting Resident #34 with transfers.

Review of the facility policy titled, Gait/Transfer/Walking Belts

Based on record review, observation, resident interview, staff interview, review of the facility policy, and review online medication resources, the facility failed to ensure resident medications were given as ordered. This affected one (#1) of three residents reviewed for medications. The facility census was 38 residents.

Findings include:

Review of the medical record for Resident #1 revealed an admission date of 06/02/22 with diagnoses including atrial fibrillation, hypertension, and peripheral vascular disease.

Review of the service plan for Resident #1 dated 06/02/22 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs).

Review of the May 2023 monthly physician orders for Resident #1 revealed an order dated 01/17/23 for the resident to receive the antacid famotidine one 20 milligram (mg) tablet at 6:00 A.M.

Review of the nurse progress note for Resident #1 dated 05/22/23 revealed an unidentified nurse gave famotidine ordered at 6:00 A.M. with 8:00 A.M. medications.

Review of the May 2023 medication administration record (MAR) for Resident #1 revealed famotidine was scheduled to be given at 6:00 A.M. and was not signed off as given during medication pass observation on 05/22/23 at 9:07 A.M.

Observation on 05/22/23 at 9:07 A.M. revealed Resident #1 was in bed and had finished eating approximately 75 percent (%) of his breakfast. Licensed Practical Nurse (LPN) #170 administered famotidine 20 mg tablet along with the resident's other 8:00 A.M. medications.

Interview on 05/22/23 at 9:10 A.M. with LPN #170 confirmed famotidine was ordered to be given at 6:00 A.M., but the pharmacy had sent the dose of famotidine in a pack with the 8:00 A.M. medications. LPN #170 confirmed famotidine was ordered for heartburn and should be given prior to eating, and she was going to contact the pharmacy so they would send the medication with the 6:00 A.M. medications, and the resident would receive at the correct time.

Interview on 05/22/23 at 1:30 P.M. with the Director of Nursing (DON) confirmed Resident #1's famotidine was ordered to be given at 6:00 A.M. so he would receive it before meals.

Review of the facility policy titled, Medication and Treatment Administration-Assistance