Brookdale Englewood

Based on medical record review, staff interview, resident interview, review of facility self-reported incidents (SRIs), and review of the facility policy, the facility failed to prevent resident to resident sexual abuse. This affected two (Residents #20 and #28) of three residents reviewed for abuse. The facility census was 48 residents.

Findings include:

Review of the medical record for Resident #28 revealed an admission date of 06/22/23 with diagnoses including intellectual disability, depression, anxiety disorder and cardiomegaly.

Review of the Short Portable Mental Status Questionnaire (SPMSQ) for Resident #28 dated 06/10/25 revealed the resident had mild cognitive impairment.

Review of the personal service plan for Resident #28 dated 11/27/25 revealed the resident required verbal and physical prompts for activities of daily living (ADLs).

Review of the progress note for Resident #28 dated 04/14/26 revealed Care Giver (CG) #50 called the nurse to the resident's apartment because he heard Resident #28 yelling for help. When CG #50 entered the room, he observed Resident #28 and Resident #20 standing next to one another both naked from the waist down. CG #50 reported he separated the residents immediately, asked them to pull up their pants and then used the walkie to call for the nurse. CG #50 then returned Resident #20 to his apartment.

Review of the medical record for Resident #20 revealed an admission date of 01/27/24 with diagnoses including congestive heart failure, hypertension and osteoarthritis.

Review of the SPMSQ for Resident #20 dated 02/17/25 revealed the resident had moderate cognitive impairment.

Review of the personal service plan for Resident #20 dated 02/04/26 revealed the resident required help with set-up for eating, dressing and grooming and was able to bathe and toilet independently. Resident #20 was independent with mobility using a cane.

Interview on 04/29/26 at 2:30 P.M. with Resident #20 confirmed he could not recall the incident on 04/14/26.

Interview on 04/29/26 at 2:55 P.M. with CG #50 confirmed on 04/14/26 he was doing rounds when he heard Resident #28 call out for help. When CG #50 entered the room to check on the resident he observed Resident #28 and Resident #20 standing next to one another both completely naked from the waist down. Resident #28 was facing toward the wall and Resident #20 was standing slightly behind her and to the side. CG #50 reported he told the residents to step away from each other and pull up their pants which they did. CG #50 then called on the walkie for the nurse. CG #50 reported he had not observed the residents touching one another, and neither resident was able to provide information about what had happened between them.

Interview on 04/29/26 at 3:10 P.M. with the Administrator and the Director of Nursing (DON) confirmed neither Resident #28 nor Resident #20 had the cognitive capacity to consent to sexual activity. They confirmed they had placed both residents on one-on-one supervision since the incident on 04/14/26 in which the residents were found alone together in Resident #28's room with both residents naked from the waist down after Resident #28 had called for help. The Administrator and DON confirmed neither resident was able to report what had transpired between them. They stated they did not consider the incident to be sexual contact because CG #50 had not witnessed the residents touching one another.

Interview on 04/29/26 at 5:00 P.M. with Resident #28 confirmed she could not recall the incident on 04/14/26.

Review of the facility (SRIs) for April 2026 revealed there was no investigation initiated for Residents #28 and #20 regarding the incident on 04/14/26.

Review of the facility policy titled Abuse, Neglect and Exploitation revised March 2026 revealed the facility was committed to maintaining an environment free of abuse, neglect and exploitation and any instances would be taken seriously, promptly reported and investigated. The first step after abuse was reported would be protection of the resident and provision of any medical attention needed. For a resident-to-resident incident, both residents should be evaluated for a change in condition.

This violation represents noncompliance investigated under Complaint Number OH00170504.

Based on record review, observation, staff interview, and policy review the facility failed to ensure an insulin pen needle was primed prior to the administration of insulin. This affected one Resident (#47) of one reviewed for the administration of insulin. The facility census was 47.

Findings included:

Medical record review for Resident #47 revealed an admission date of 04/15/24. Medical diagnoses included dementia, hypertension and diabetes.

Observation on 10/07/25 at 10:12 A.M., of the medication administration revealed Licensed Practical Nurse (LPN) #112 collected a blood sugar reading for Resident #47. The resident required four units of Humalog insulin. LPN #112 took the Humalog insulin pen out of the medication drawer, placed the needle on the pen, dialed the insulin pen to four units, and administered the four units of insulin to Resident #47. At no time was LPN #112 observed priming the insulin pen prior to administering the insulin.

Interview on 10/07/25 at 10:12 A.M., LPN #112 verified she had not primed the needle prior to administering the insulin and said she was not aware she needed to prime the needle prior to administration.

Review of the policy titled Instructions for use for Humalog Kwik-Pen dated 2007 revealed to prime before each injection with two units of insulin. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.

Based on review of the Tuberculosis (TB) Risk Assessment and staff interview, the facility failed to update their Tuberculosis (TB) Risk Assessment annually. This had the potential to affect all 47 residents who resided in the facility. The facility census was 47.

Findings included:

Review of the facility's TB Risk Assessment revealed it was filled out however, was undated and unsigned.

Interview with the Executive Director (ED) on 10/07/25 at 2:22 P.M., verified the TB Risk Assessment had not been signed or dated. The ED was unsure when it was completed. She verified the TB Risk Assessment form was supposed to be completed annually.

Based on observation, staff interview, and policy review the facility failed to ensure hands were washed after medication administration. This affected two Residents (#47 and #3) of two residents reviewed for medication administration. In addition, the facility failed to ensure a glucometer was cleaned properly after a blood sugar check and hands were washed between checking the blood sugar and administering the insulin. This affected one Resident (#47) of one resident reviewed for blood sugar checks. The facility identified there were two residents who required blood sugar checks. The facility census was 47.

Findings included:

1. Observation of a medication administration on 10/07/25 at 7:43 A.M., revealed Resident #10 was standing at the medication cart and the Licensed Practical Nurse (LPN) #112 with gloved hands applied eye drops in Resident #10's eyes. LPN #112 removed her gloves and proceeded to pull the medication for Resident #3. She removed the following medications from their packaging with her bare hands: Allopurinol (blood pressure medication) 300 milligrams (mg), Eliquis (a blood thinning medication) 5 mg, Fenofibrate (a cholesterol reducing medication) 145 mg, Iron (a supplement) 325 mg, Synthroid (a thyroid medication) 75 mg, Lopressor (a blood pressure medication) 25 mg, a Stress (a supplement) tablet and a Vitamin D-3 and put them in the cup. She proceeded into the Resident #3's room and administered the medication. LPN #112 then went to the sink and washed her hands. She left the room and went back to the medication cart and removed the blister packaging of medications for Resident #9. She pushed out the following medication with her bare hands and placed the medication in the medication cup: Plavix (cholesterol lowering medication) 75 mg, Cranberry (a supplement) 250 mg, Finasteride (a prostate medication) 5 mg, Meloxicam (pain medication) 7.5 mg, Methenamine (an antiseptic medication) one gram, Protonix (acid reducing medication) 40 mg, Prevagen (a supplement for memory) 10 mg, Crestor (anti lipid) 20 mg, Men's Multi-Vitamin, Effexor (antidepressant medication) 75 mg, and Vitamin C 1,000 mg. LPN #112 went into Resident #9's room and administered the medications to the resident.

Interview with LPN #112 on 10/07/25 at 8:05 A.M., verified after placing drops in Resident #10's eyes she removed her gloves and had not washed her hands. LPN #112 verified she had touched on all the dirty blister packs, while pushing the medications out into her bare hands to place them in the medication cup one by one for Resident #3 and Resident #9 and had not washed her hands before touching the pills.

2. Observation of a blood sugar check on 10/07/25 at 10:12 A.M., revealed LPN #112 placed on gloves and checked Resident #47's blood sugar and removed the test strip where blood had been collected and discarded it into the trash. With the same gloves on LPN #112 drew up the insulin and administered the insulin to Resident #47. LPN #112 went back to the medication cart and cleansed the glucometer with a alcohol swab.

Interview with LPN #112 on 10/07/25 at 10:20 A.M., verified she used the same gloves to check the blood sugar, draw up, and administer the insulin to Resident #47. LPN #112 verified she had not used the correct cleansing agent for the glucometer. LPN #112 said the proper cleansing agent was locked away in a storage cabinet and not on her medication cart.

Review of the policy titled Infection Control dated 05/01/25 revealed associates should wash their hands immediately or as soon as practicable after removal of gloves.

Review of the policy titled Handwashing dated 09/01/24 revealed proper hand washing practices should be used at all times.

Policy Detail:

1. Hand washing is to be done:

· Before starting work

· When hands are visibly soiled

· After contact with soiled or contaminated articles, such as, waste removal and articles that are

contaminated with bodily fluids

· Before and after eating

· After toileting or after personal grooming (combing hair)

· After smoking

· After coughing, sneezing, or blowing your nose

· After handling food

· After removal or changing of gloves

· After any other potential contamination

Review of the policy titled How to Clean and Monitor a Blood Glucose Glucometer undated revealed to use Super Sani-Cloth and when using the product on the glucometer wait 2 minutes afterwards until the bactericidal, tuberculocidal, and virucidal properties can be effective.

Based on observation, staff interview, and policy review the facility failed to serve all food in a manner that protects against contamination. This had the potential to affect 10 Residents who could order egg salad for lunch. The census was 47.

Observation on 10/07/25 at 11:45 A.M., revealed a bowl of egg salad sitting on the counter covered with plastic wrap. The egg salad on the counter was not observed sitting on ice.

Observation on 10/07/25 at 11:50 A.M., revealed the temperature of the egg salad was 52 degrees Fahrenheit. Sous Chef #127 measured the temperature of the egg salad with a facility thermometer. Interview with Sous Chef #127 at 11:50 A.M., verified the temperature of the egg salad was too high. Sous Chef #127 stated cold food should be served at a temperature below 40 degrees. Sous Chef #127 had enough egg salad to serve 10 residents and continued to serve the egg salad with no interventions to decrease the temperature.

Observation on 10/07/25 at 11:52 A.M. revealed Sous Chef #127 handling paper menus from the dining room and then handling buns and bread with the same gloved hands. Sous chef #127 had not changed gloves between handling the paper menus and the bread products. Interview at the time of the observation with Sous Chef #127 verified they had not changed gloves in between handling the paper menus and the bread products.

Interview on 10/07/25 at 12:10 P.M., with Dining Service Coordinator (DSC) #139 verified cold food should be kept at a temperature below 40 degrees Fahrenheit. DSC #139 stated that cold food should be sitting on ice during service to ensure the temperature stays in the correct range. DSC #139 said the expectation for staff was they should have changed their gloves between handling food and touching anything else in the kitchen. DSC #139 stated they have not completed recent in-service training on glove usage in the kitchen. DSC #139 stated no glove usage audits had been performed in the kitchen.

Review of the undated facility policy titled Sanitation and Food Safety revealed that foods must be kept at a safe temperature at all times. The policy documented cold foods must be stored in refrigerators or iced down to maintain a temperature of 40 degrees or below.

Review of the facility policy titled Use of Gloves - DS 03.006 last revised 08/24 revealed gloves should be changed and hands washed in between tasks and after any interruption or potential contamination.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure potentially hazardous chemicals were properly secured. This had the potential to affect 12 of 12 residents residing on memory care unit. The facility census was 49 residents.

Findings include:

Observation on 12/10/24 at 3:37 P.M. of the kitchen area of memory care unit revealed there were two bottles of blue liquid in unlabeled squeeze bottles in an unsecured cabinet under the sink.

Interview on 12/10/24 at 3:37 P.M. with Care Associate (CA) # 23 confirmed she believed the liquid in the bottles was dishwashing liquid and the cabinet on the memory care unit was unlocked and accessible to the residents on the unit.

Interview on 12/10/24 at 4:10 P.M. with the Health and Wellness Director (HWD) confirmed there were two bottles of dishwashing liquid which being stored in an unlocked cabinet on the memory care unit.

Interview on 12/10/24 at 4:35 P.M. with the Maintenance Director (MD) confirmed the magnet lock system on the kitchen cabinet in the memory care unit was broken. The MD confirmed the dishwashing liquid should be stored in a locked cabinet.

Review of the facility policy titled Storage of Chemicals and Toxic Materials dated August 2024 revealed all chemicals and toxic materials must be stored securely away from food.