Brookdale Centennial Park

Based on personnel file review and staff interview, the facility failed to ensure newly hired employees took a first aide training course within sixty days of hire as required. This affected two (#44 and #37) out of six personnel files reviewed and had the potential to affect all 26 residents who resided in the facility. The facility census was 26.

Findings included:

Review of personnel file for Resident Care Associate (RCA) #44 revealed a hire date of 06/06/25. Further review revealed there wasn't evidence of first aide training for the employee.

Review of personnel file for RCA #37 revealed a hire date of 01/09/25. Further review revealed there wasn't evidence of first aide training for the employee.

Interview with the Business Office Manager (BOM) #29 on 10/06/25 at 1:53 P.M. confirmed RCA #44 and #37 had no completed first aide training.

Based on personnel file review and staff interview, the facility failed to ensure nurse aide registry checks were completed or two staff members out of seven reviewed for personnel files. This affected all the residents who resided in the facility. The facility census was 26.

Findings included:

Review of Licensed Practical Nurse (LPN) #50's personnel file revealed a hire date of 08/05/24. Further review of LPN #50's personnel file revealed no evidence the staff was checked against the nurse aide registry.

Review of LPN #51's personnel file revealed a hire date of 05/19/25. Further review of LPN #51's personal file revealed no evidence the staff was checked against the nurse aide registry.

Interview with Business Office Manager (BOM) #29 confirmed there wasn't evidence LPN #50 and #51 was checked on the nurse aide registry. BOM #29 said she didn't know she was supposed to check the staff on the nurse aide registry prior to employment.

Based on observation and staff interview, the facility failed to ensure the dryer vents were free from lint. This had the potential to affect all 26 residents who resided in the facility. The facility census was 26.

Findings included:

Observation of the laundry room on 10/06/25 at 8:31 A.M. revealed there were three dryers that was filled with lint.

Interview with the Health and Wellness Director (HWD) #28 on 10/06/25 at 8:32 A.M. confirmed the dryer vent was full of lint and should have been emptied.

Based on record review and staff interview, the facility failed to update their Tuberculosis (TB) Risk Assessment worksheet annual. This had the potential to affect all 26 residents who reside in the facility. The facility census was 26.

Findings included:

Review of the TB Risk Assessment worksheet revealed it was dated 01/2024 and signed by the previous Executive Director (ED).

Interview with the Health and Wellness Director (HWD) on 10/06/25 at 10:48 A.M. confirmed the TB Risk Assessment should be updated yearly and confirmed it was last dated 01/2024.

Based on record review, observations, staff interviews and policy, the facility failed to ensure a glucometer was cleansed/disinfected with the appropriate wipes. This affected one (#12) of one resident reviewed for blood sugar check and had the potential to affect four (#3, #5, #12 and #13) residents who share the glucometer. The facility also failed to ensure hands were washed when changing gloves during a dressing change. This affected one (#3) of one residents reviewed for wound care. The facility census was 26.

Findings included:

1. Observation of Licensed Practical Nurse (LPN) #48 on 10/06/25 at 7:28 A.M. revealed she took a blood sugar for Resident #12 and cleansed the glucometer with an alcohol swab and put it in the drawer.

Interview with LPN #48 on 10/06/25 at 7:40 A.M. confirmed she should have used a Sani-wipe on the glucometer because of the exposure of blood to the other residents. She didn't have any Sani-wipes on her cart. LPN #48 confirmed the glucometer is shared between four (#3, #5, #12 and #13) residents.

Review of the policy entitled How to Clean and Monitor a Blood Glucose Glucometer 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.

2. Medical record review for Resident #3 revealed an admission date of 04/11/24. Her medical diagnoses included pain in left shoulder, malignant neoplasm of breast, unsteady gait, dermatitis, lymphoma, anemia, and respiratory disorders.

Observation of a dressing change for Resident #3 on 10/60/25 at 1:10 P.M. revealed Licensed Practical Nurse (LPN) #48 put on fresh gloves and the resident was turned on her side and brief was pulled away. LPN #48 proceeded to cleanse Resident #3's wound and removed her gloves and then placed the medication on the wound and changed her gloves and then placed a bandage on the wound and tied up the trash and left the room and walked down the hall.

Interview with LPN #48 on 10/06/25 at 1:17 P.M. confirmed since it wasn't a sterile dressing change she didn't think she had to change her gloves in between dirty to clean. LPN #48 stated she didn't wash her hands before leaving the room because the Hoyer lift was in the bathroom. LPN #48 reported she should have washed her hands before leaving the room.

Review of the policy entitled Routine Dressing Changes - Skin Tears /Abrasions/Closed Wounds dated 11/01/18 revealed gently remove the old tape and dressing. Place soiled dressing in trash bag. Remove gloves and put in trash bag. Wash hands with soap and water. Assess the wound for drainage, size, color, and any signs of infection, don disposable/sterile gloves. Clean the wound with the prescribed cleaning solution and throw used pads and swabs in trash bag. Wash the skin around the wound with soap and water and pat dry with a sterile 4 X 4 gauze dressing. Avoid oil based soaps since they may interfere with dressing adherence. Apply skin protectant if physician ordered and then apply prescribed dressing or place 4 X 4 gauze on wound, securing gauze with tape (paper tape preferred) and following manufacturer instructions. Remove gloves and discard in trash bag. Discard disposable items according to Standard Precautions and wash hands with soap and water.

Based on observations and staff interviews, the facility failed to ensure food was dated when opened, food was discarded when expired and to ensure the kitchen was clean. This had the potential to affect all 26 residents residing in the facility. The facility census was 26.

Findings included:

Observation of the kitchen on 10/06/25 at 11:26 A.M. revealed in the freezer there were opened packages of beef, bag of peas, two bags of fries, four bags of sausage patties, two bags of sliced turkey that appeared freezer burned, and a big bag of nuts and didn't have dates of opening on the packages.

Observation of the refrigerator in the kitchen on 10/06/25 at 11:30 A.M. revealed there was bag of sugar snap peas, bag of broccoli, bag of onions bag of lettuce, two bags of potatoes, celery unwrapped, bag of spinach, and 30 eggs that were out of the box and all of these items had been opened and not dated. Further observation revealed there was a container of horseradish dated 05/25/25, and 30 eggs that were not dated. there was a rank smell in the refrigerator.

Observation in the cupboards in the kitchen on 10/06/25 at 11:35 A.M. revealed there were opened packages of honey, potato chips, white icing, croutons, and a bag of stuffing mix, a bag of chocolate chips, that were not dated.

Further review of the kitchen on 10/06/25 at 11:45 A.M. revealed the fronts of the cabinets were sticky with a yellow film buildup on them, the fronts of the freezer and refrigerator doors were sticky and had a yellowish film on the front of the doors. Inside of the freezer and refrigerator had leakage of brownish reddish substances on the bottom of them. The prep table legs had build up of a sticky substance. Behind the dishwasher there were streaks of yellow substance and built up dirt on the walls down to the floor. The back of the three compartment sink nozzles had caked on substance on them. The floors in the entire kitchen were sticky.

Interview with the Kitchen Manager #32 on 10/06/25 at 11:46 A.M. revealed he was new to the facility and hadn't had a chance to go through everything. Kitchen Manager #32 confirmed multiple food items were not dated when opened, the out of date food. Kitchen Manager #32 stated it was not the practice of the kitchen to serve out of date food to the residents. Kitchen Manager #32 confirmed the kitchen was dirty and needed to be cleaned.

Interview with the Health and Wellness Director (HWD) on 10/06/25 at 12:00 P.M. confirmed she had not been in the kitchen lately and didn't know it was in this condition. HWD reported there wasn't a policy for the kitchen they follow the regulations.

Based on review of the facility submitted Self-Reported Incident (SRI), medical record review, staff interview, Nurse Practitioner (NP) interview, hospital record review and review of facility policy, the facility failed to ensure medications were available and administered per physician orders and further failed to ensure accurate medication administration documentation. This resulted in Real and Present Danger and the potential for serious life-threatening harm, negative health outcomes and/or death to Resident #09 on 01/23/25 when the facility failed to ensure the resident's Xarelto (used to treat blood clots) was available and administered per physician order for approximately 10 months. Subsequently, on 01/23/25, Resident #09 was admitted to the hospital due to a right lower extremity deep vein thrombosis (DVT - blood clot) and received intravenous (IV) heparin (anticoagulant) treatment for the DVT. Additionally, Resident #05 was placed at risk for the potential for serious life-threatening harm, negative health outcomes, and/or death when physician ordered metoprolol succinate (used to treat high blood pressure) was unavailable for administration for approximately eight months. This affected two (#09 and #05) of nine residents reviewed for medication administration. The facility census was 27.

On 03/10/25 at 12:15 P.M., the Executive Director (ED), Health and Wellness Director (HWD) #106, and Area Nurse (AN) #104 were notified Real and Present Danger began on 01/23/25 when Resident #09 was admitted to the hospital due to a right lower extremity DVT, requiring IV heparin treatment. On 01/23/25, HWD #106 was notified by agency Licensed Practical Nurse (LPN) #300 that some residents' medications were unavailable for administration. Upon further investigation, HWD #106 determined Resident #09's physician ordered Xarelto had not been available for administration since March 2024 (approximately 10 months). Additionally, HWD #106 determined Resident #05's physician ordered metoprolol succinate had been unavailable for administration since May 2024 (approximately eight months), which placed the resident at increased risk for complications associated with high blood pressure, including, but not limited to, heart attack, stroke, and heart failure.

The Real and Present Danger was abated on 03/12/25 when the facility implemented the following corrective actions:

On 01/23/25, Resident #09 was transferred to the hospital for treatment related to a right lower extremity DVT.

On 01/23/25, agency LPN #300 reported to HWD #106 that some resident medications were unavailable for administration. HWD #106 requested a list of all unavailable medications.

On 01/24/25, HWD #106 completed a medication review for all residents and identified Resident #09 did not have Xarelto available for administration from 03/13/24 through 01/22/25 and Resident #05 did not have metoprolol succinate available for administration from 05/01/24 through 01/23/25. All missing medications were reported to the pharmacy and delivered on 01/25/24.

On 01/24/25, seven LPNs (LPN #110, LPN #111, LPN #112, LPN #113, LPN #114, LPN #116, and LPN #118), who were identified as documenting the administration of unavailable medications and not following up to ensure medications were available for Resident #09 and Resident #05, were suspended pending the outcome of the investigation. Additionally, three former LPNs (LPN #109, LPN #115, and LPN #117) were identified as being involved in documenting the administration of unavailable medications for Resident #09 and Resident #05.

Beginning on 01/24/25, the facility only utilized licensed agency nurses. HWD #106 educated all licensed nurses on immediate reporting of unavailable medications to her prior to the start of their first shift.

Beginning on 01/24/25, HWD #106 or designee will ensure all newly hired licensed nurses are educated on the facility's medication administration, medication ordering, medication reordering and receiving medication deliveries policies and procedures utilizing in-person and online resources prior to their first scheduled shift.

On 01/27/25, the ED, District Director of Clinical Services (DDCS) #119, HWD #106, Vice President of Clinical Services (VPCS) #123, VP of Operations (VPO) #124, District Director of Operations (DDO) #125, and Associate General Counsel (AGC) #126 conducted a root cause analysis and determined the licensed nurses did not follow the seven rights of medication administration, which included the right resident, the right medication, the right dose, the right time, the right route, the right reason, and the right documentation.

On 01/27/25, DDCS #119 reviewed the facility's policies and procedures for medication administration and ordering/reordering/receiving medications and determine the policies and procedures were in compliance with industry standards.

On 01/29/25, Area Health and Wellness Director (AHWD) #120 and DDCS #119 completed a medication cart audit by comparing the current Medication Administration Records (MAR) for all facility residents to the medications available in the medication cart, with no discrepancies identified.

On 01/31/25, Pharmacy Account Manager (PAM) #121 completed a medication audit for all residents to ensure physician orders matched the medications delivered, with no concerns identified.

By 01/31/25, HWD #106 and DDCS #119 assessed all residents for negative outcomes, with no additional concerns identified.

Beginning on 03/10/25, HWD #106 or designee will perform medication cart audits weekly for four weeks to ensure all resident medications are available for administration. Any discrepancies will be addressed immediately.

Beginning on 03/10/25, HWD #106 or designee will audit all resident MARs daily to validate accurate documentation and administration of medications for two weeks. Any discrepancies will be addressed immediately.

Beginning on 03/10/25, HWD #106 or designee will audit pharmacy delivery records for 10 residents for two weeks to ensure all medications are ordered, delivered, and available in the facility.

Beginning on 03/12/25, HWD #106 or designee will observe medication administration of five residents with all newly hired licensed nurses within three days of their first assignment to ensure compliance with medication administration and ordering/reordering of medications, in accordance with facility policies and procedures.

By 03/14/25, DDCS #119 will file a report with the Ohio Board of Nursing (OBN) regarding the 10 LPNs (LPN #109, LPN #110, LPN #111, LPN #112, LPN #113, LPN #114, LPN #115, LPN #116, LPN #117, and LPN #118) involved in documenting the administration of unavailable medications for Resident #09 and Resident #05.

Beginning on 03/27/25, the facility will be contracted with a new pharmacy to provide monthly packaging and delivery of resident medications.

Beginning on 03/28/25, HWD #106 or designee will audit all resident medications and physician orders, one-time monthly for four months, to ensure availability of medications for administration.

Interview on 03/10/25 at 11:30 A.M. with LPN #102 verified the facility provided education on medication administration, including accurate documentation and ordering/reordering medications.

Review of seven (Resident #06, Resident #10, Resident #13, Resident #21, Resident #25, Resident #28, and Resident #29) additional open resident records revealed no concerns.

Although the Real and Present Danger was abated on 03/12/25, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

Review of a facility submitted SRI, created on 01/29/25 at 11:59 A.M., revealed on 01/23/25, an agency nurse reported to the HWD that several medications were not available to administer to residents during his medication pass. The HWD instructed the agency nurse to provide her with the list of medications needed. The HWD called the pharmacy regarding these unavailable medications. During the call, HWD was advised one of the medications had not been dispensed since May of 2024 (metoprolol succinate for Resident #05), and another medication (Xarelto for Resident #09) had not been dispensed since March of 2024. An investigation was initiated, and it was found the two medications (metoprolol succinate and Xarelto) were signed off as administered by several nurses during this time period. One resident (Resident #09) was identified as potentially having had a serious negative outcome due to a missed medication. The facility unsubstantiated the allegation on 01/30/25 at 2:58 P.M.

1) Review of Resident #09's medical record revealed an admission date of 09/24/21. Diagnoses included anxiety disorder, disease of upper respiratory tract, edema, major depressive disorder, hypertension, and long term (current) use of anticoagulants. On 01/30/25, an additional diagnosis of chronic embolism and thrombosis of deep veins of lower extremity was added.

Review of the Personal Service Assessment (PSA), dated 02/17/25, revealed Resident #09 was mildly cognitively impaired and required medication administration.

Review of Resident #09's physician orders revealed on 03/12/24, Eliquis (used to treat and prevent blood clots) was discontinued and a new order was given to start Xarelto 20 milligrams (mg) one time daily.

Review of the MAR from 03/13/24 through 01/22/25 revealed licensed nurses documented Resident #09's Xarelto was administered as ordered, with only four days (07/20/24, 10/27/24, 11/24/24, and 12/08/24) documented as not administered.

Review of Resident #09's progress notes from 03/13/24 through 01/22/25 revealed no evidence the resident's Xarelto was documented as unavailable for administration. Further review of the progress notes revealed no evidence the facility's nursing management, the physician or the pharmacy were notified that Xarelto was unavailable for administration to Resident #09.

Review of a progress note dated 01/23/25 revealed Resident #09 had an episode of shortness of breath and edema to her lower leg. Resident #09 was transferred to the hospital.

Review of hospital discharge documents revealed Resident #09 was admitted to the hospital on 01/23/25 due to a right lower extremity DVT. Further review revealed Resident #09 was on Xarelto for atrial fibrillation (A-fib) but still developed a lower extremity DVT while on the medication. Xarelto was discontinued and replaced with a heparin drip while in the hospital. Resident #09 discharged from the hospital on 01/29/25 with new orders for warfarin (used to prevent blood clots) five mg, one tablet by mouth daily, and Lovenox (injectable blood thinner) 80 mg, inject subcutaneously every 12 hours.

2) Review of Resident #05's medical record revealed an admission date of 04/11/24. Diagnoses included other respiratory disorder, hemiplegia and hemiparesis, atherosclerotic heart disease, A-fib, Type II diabetes, major depressive disorder, hypertension, and lymphedema.

Review of the PSA, dated 10/24/24, revealed Resident #05 was cognitively intact and required medication administration.

Review of a physician order dated 04/12/24 revealed Resident #05 was ordered metoprolol succinate extended release (ER) 25 mg once daily for hypertension.

Review of the MAR from 05/01/24 through 01/23/25 revealed Resident #05's metoprolol was documented as administered on each of the days, except for two (07/20/24 and 12/08/24).

Review of Resident #05's progress notes from 05/01/24 through 01/23/25 revealed no evidence the resident's metoprolol was unavailable for administration and further review revealed no evidence the physician, nursing management or the pharmacy were notified the medication was unavailable for administration.

Further review of the medical record from 05/06/24 through 01/18/25 revealed the following Blood Pressure (BP) readings for Resident #05: 05/06/24, 144/70 millimeters of mercury (mm/Hg); 05/07/24, 136/68 mm/Hg; 05/11/24, 133/66 mm/Hg; 06/03/24, 141/70 mm/Hg; 07/08/24, 140/72 mm/Hg; 08/14/24, 140/70 mm/Hg; 09/11/24, 138/68 mm/Hg; 11/12/24, 138/76 mm/Hg; 12/13/24, 180/110 mm/Hg; and 01/18/25, 147/68 mm/Hg. Resident #05's metoprolol was ordered and delivered to the facility on 01/25/25. Following the restart of the medication, Resident #05's BP reading on 01/27/25 was 116/74 mm/Hg (according to the American Heart Association, a BP of less than 130/80 mm/Hg should be targeted for individuals over 65 years of age).

An interview on 03/07/25 at 1:30 P.M. with the ED, HWD #106, and AN #104 confirmed the facility completed an investigation related to the missed medications for Resident #09 and Resident #05 and further verified their investigation determined Resident #09 did not have Xarelto administered as ordered from 03/13/24 through 01/22/25 and Resident #05 did not have metoprolol administered from 05/01/24 through 01/25/25.

An interview on 03/07/25 at 2:00 P.M. with HWD #106 revealed she spoke with the facility's pharmacy, who confirmed Resident #09's Xarelto had never been delivered to the facility (ordered to begin on 03/13/24) for administration. HWD #106 verified licensed nursing staff documented on Resident #09's MAR that the medication had been administered when it was unavailable in the facility.

A follow-up interview on 03/07/25 at 3:30 P.M. with the ED, HWD #106, and AN #104 verified Resident #05's metoprolol (from 05/01/24 through 01/24/25) and Resident #09's Xarelto (from 03/13/24 through 01/22/25) were not delivered to the facility by the pharmacy and, therefore, were not administered as documented on the MARs.

An interview on 03/10/25 at 1:03 P.M. with NP #108 confirmed she was unaware Xarelto had been unavailable for administration to Resident #09. NP #108 further stated Resident #09 would have benefited from taking her medication and verified not having Xarelto administered as ordered contributed to the resident's right lower extremity DVT. NP #108 confirmed Resident #05 was placed at increased risk related to not having metoprolol as ordered.

Review of the facility policy titled, Medication Administration, dated December 2020, revealed for oral medication administration, the nurse would prepare by doing the following: locate medication from the secured location, obtain water or juice to assist the resident in swallowing his/her medication, check the resident's medication record and confirm administration for specific medication time, punch or remove the medication from the bubble pack or other container into the resident's hand or into a medicine cup, observe the resident taking the medication, and initial in each square on the resident's MAR that corresponds with the scheduled assistance time and date for the medications.

Review of the facility policy titled, Medication and Treatment - Storage, Handling, Distribution, Disposition, and Payment, dated 03/31/22, revealed the community was responsible for obtaining newly ordered medication or refills for medication and treatment orders, unless otherwise agreed upon with the resident, family, or legally responsible party. Associates should follow a consistent procedure in accepting medications. Errors noted in receiving medications should be brought to the attention of the executive director (ED), HWD, or designee. Before signing to accept the delivery, the nurse or designee must reconcile the medications, including controlled substances, in the package with the delivery ticket. If an error is identified in receiving the medications from the pharmacy, the nurse or designee verifying the order should inform the delivery agent of any discrepancies and note them on the delivery ticket. Medication assistance and/or treatment shall be provided in a safe and timely manner, and as prescribed by the resident's health care provider. Licensed nurses prepare, assist and/or administer and document medications. The nurse assisting with the medication should observe the resident ingesting the medication prior to initialing the resident's medication record and record it immediately after medication assistance. Trained and licensed associates administering or assisting with medications should document medications administered or assisted with on the MAR. Documentation of medications administered /assisted, should occur promptly after the resident has taken the medication. Medication and/or treatment errors should be reported promptly.

This violation represents non-compliance investigated under Complaint Number OH00162191.

Based on medical record review, staff interviews, review of facility investigation, review of a facility Self-Reported Incident (SRI), and review of facility policy, the facility failed to ensure Resident #26 was provided with adequate care and services to prevent the resident from sustaining injuries from an unwitnessed fall. This resulted in Actual Harm when Resident Care Assistant (RCA) #41 transferred Resident #26 to her bed on 11/11/24, left the bed in the highest position, and left the resident's room to resume her duties. Resident #26 was later discovered on the floor near her bed from an unwitnessed fall. Consequently, the resident sustained a large hematoma (A collection of blood within the skull, either between the brain and the skull or within the brain. Hematomas to the head can be life-threatening and require immediate treatment.) and bruising on the right side of her forehead, bruising to the resident's nose and abrasions to the resident's left knee. This affected one (#26) of three residents reviewed for falls. The facility census was 31.

Findings Include:

Review of the medical record for Resident #26, revealed an admission date of 09/05/23. Diagnoses included, but not limited to vascular dementia, mood disturbance and anxiety, hypertension, cerebral atherosclerosis, aphasia following cerebral infarction, transient cerebral ischemic attack and resident was receiving hospice services.

Review of Fall Risk Evaluation - Move in and Change in Condition for Resident #26 dated 09/05/23, revealed the resident was listed as a level two fall risk indicating the resident was at risk for falls. The staff were to determine the resident's fall risk based on the responses on the form and the fall level may be increased based on a nurses' clinical judgment. There were no additional fall risk evaluations completed on the resident.

Review of the incident log revealed an entry dated 11/11/24 at 10:30 A.M. indicating Resident #26 had an unwitnessed fall from her bed and was found lying on the floor. Interventions included when resident was displaying increase anxiety and restless like behaviors, resident will be in common area in Broda chair for close monitoring. There was no documentation related to the staff member leaving the bed in the highest position then leaving the resident unattended.

Review of the Personal Service Plan for Resident #26 revised 11/08/24, revealed the resident had difficulty in communicating needs and preferences, was not always oriented to person, place or time, resident displayed anxious, disruptive or obsessive behaviors, and universal fall precautions included the resident's bed should be kept locked and in its lowest position when resident is resting in bed. Resident #26 was found on the floor on 09/15/24, 09/16/24 and 10/09/24 with no other details about the falls. Resident #26 had a fall on 11/11/24 and interventions included when resident is displaying increased anxiety and restlessness like behaviors, the resident will be in a common area while seated in a Broda chair for close monitoring. Resident #26 was a two-person assist for all transfers and required a mechanical lift (Hoyer) for all transfers.

Review of a Post Fall progress note for Resident #26 dated 11/11/24 at 11:34 A.M. and authored by Licensed Practical Nurse (LPN) #28, revealed the resident had an unwitnessed fall on 11/11/24 at 10:30 A.M. when she was found on the floor beside the resident's bed. The resident was unable to explain what happened and there were physical signs of head injury such as bruising, a bump on her forehead and bruising on her nose. Hospice was notified and ice was applied to the resident. Resident #26 did not articulate a verbal response reference to pain; however, the resident was holding her left knee and a small abrasion was noted on the knee. The healthcare provider was notified, and comfort medications were ordered and to monitor for status change. The power of attorney was contacted and noted there were concerns about the resident's fall and would come visit. Interventions were to move the resident to the common area when displaying anxiety and restless like behaviors.

Review of the facility's fall investigation completed by Corporate LPN #38 revealed the following:

a. On 11/11/24, Resident #26 was found by agency CNA #40 lying on her right side on the floor near the bedside and the resident's bed was in the highest position. CNA #40 called out for Agency CNA #45 who then notified LPN #28 that Resident #26 was on the floor. LPN #28 responded and assessed the resident with a large hematoma on the right side of resident's forehead. Resident #26 was unable to verbalize what happened due to severe cognitive impairment related to disease process. LPN #28 questioned CNA #40 on who put the resident in the bed, and CNA #40 stated RCA #41 had placed the resident in bed.

b. On 11/11/24, Resident #26 was unable to be interviewed due to cognition.

c. On 11/12/24, Corporate LPN #38 was made aware of the situation, who then contacted human resources and RCA #41 was suspended.

. On 11/13/24, agency CNA #40 was interviewed and stated she noticed on 11/11/24 at 10:10 A.M., Resident #26 had been removed from the common area, so she asked RCA #41 about the resident's whereabouts. RCA #41 stated she put the resident to bed because she kept trying to get out of her Broda chair. Agency CNA #40 informed RCA #41 if the resident was trying to get out of the chair, she would try to get out of her bed. RCA #41 stated the resident wouldn't try to get out of bed. Agency CNA #40 went to check on Resident #26 and found her on the floor at bedside lying on her right side. CNA #40 called out to agency CNA #45 to get the nurse. Agency CNA #40 reported the resident had a large hematoma on the right side of her forehead.

e. On 11/13/24, Hospice CNA #42 was interviewed and stated Resident #26 was trying to get out of her Broda chair and LPN #28 gave the resident her as needed (PRN) medication around 9:30 A.M. to help the resident with restlessness. LPN #28 leaned the chair back to help the resident relax and help prevent the resident from falling out of chair and LPN #28 continued with her other tasks. LPN #28 later learned the staff laid the resident down in bed and then the resident fell out of bed while it was in the highest position. Hospice CNA #42 indicated she went to the resident's room to check the functioning of her bed. The bed was found in the highest position, so Hospice CNA #42 used the remote to lower the bed all the way down with no functional issues.

f. On 11/13/24, LPN #28 was interviewed and stated she had given Resident #26 her PRN Ativan to help reduce the resident's restlessness behavior and Hospice CNA #42 had adjusted the resident's Broda chair. LPN #28 returned from her medication administration and became aware of Resident #26's fall when she was called to the resident's room.

g. On 11/18/24, RCA #41 was interviewed and stated on 11/11/24, Resident #26 was very restless sitting in her chair out in common area. RCA #41 stated she repositioned the resident several times because she was leaning over the side of her chair and then decided to take the resident to her room and lay her down in the bed. RCA #41 indicated this was a common practice when the resident got restless. RCA #41 stated the resident's bed was in highest position when she transferred her, and it was left that way because she couldn't get it to go down. RCA #41 stated after she got the resident in the bed, she resumed to her remaining tasks. RCA #41 stated an agency CNA informer her the resident's fell.

The investigation revealed RCA #41 placed Resident #26 in her bed by herself using a Hoyer lift and left the resident's bed elevated in the highest position. RCA #41 indicated she put Resident #26 in bed because she was trying to get out of her Broda chair. On 12/02/24, RCA #41 was terminated.

Review of a Post-Fall note for Resident #26 dated 11/11/24 at 11:34 A.M. revealed the resident had an unwitnessed fall in her room. There were physical signs of head injury due to the resident having bruising, a bump on her forehead and bruising on her nose. Hospice and the Hospice physician were notified and ordered ice to be applied to forehead and comfort care medications. Resident #26 was unable to verbalize any pain; however, the resident was holding her left knee and a small abrasion was noted. The power of attorney was contacted and had concerns about the fall and would come visit. There were no additional comments related to the fall.

Review of a nurse progress note for Resident #26 dated 11/12/24 at 3:40 P.M. and authored by LPN #28, revealed the resident complained of a headache, was given medication and the bruising continued to the resident's forehead and nose.

Review of Nurse Practitioner (NP) #50's progress notes for Resident #26 dated 11/19/24 and signed and completed on 11/22/24, revealed the resident was seen for a follow-up related to a fall and chronic management. Resident #26 was noted to have fallen on 11/11/24. The assessment revealed the resident had discoloration and a contusion across her nose and denied any acute pain during the assessment. The bruising was fading and was yellowish in color. The nursing staff reported the resident had increased lethargy and remained non-verbal. There was no documentation related to the abrasion on the resident's left knee.

Review of an SRI created 11/20/24 at 10:21 A.M. by Corporate LPN #38 for neglect/mistreatment, revealed on 11/11/24, Resident #26 was found on the floor by Agency CNA #40 lying on her right side. The resident was unable to verbalize what happened due to severe cognitive impairment. Agency CNA #40 noted the bed was in the highest position. Agency CNA #40 called out for other aides who then notified the nurse on duty. The nurse responded and assessed the resident with a large hematoma on the right side of the resident/s forehead. The investigation revealed RCA #41 placed the resident in the bed by herself using a Hoyer lift and left the bed elevated in the highest position. The SRI was substantiated for abuse, neglect or misappropriation as verified by evidence. RCA #41 was terminated, and education related to transfers and neglect was provided to the staff.

Interview with LPN #28 on 12/24/24 at 9:30 A.M., revealed she was tasked with caring for Resident #26 on 11/11/24. LPN #28 stated the resident was a two person assist using a Hoyer lift for all transfers. LPN #28 stated on 11/11/24, Resident #26 was lying in a Broda chair in the common area when RCA #41 returned the resident to her room and put her in the bed. LPN #28 noted RCA #41 put the bed in the highest position during the transfer and then left the bed in the highest position when she left the room to resume her other duties. LPN #28 verified the resident fell from her bed as it was situated in the highest position and sustained a large hematoma to the right side of her forehead and an abrasion to the left knee.

Interview with the Health and Wellness Director (HWD)/LPN #38 on 12/24/24 at 1:00 P.M., verified Resident #26 had an unwitnessed fall from her bed which was left in the highest position by RCA #41 and the resident sustained physical signs of a head injury, including a large hematoma on the resident's head, facial bruising and an abrasion on the resident's left knee. HWD/LPN #38 stated RCA #41 should have placed the bed in the lowest position after transferring Resident #26 to bed and before leaving the resident's room.

Interview with the Executive Director on 12/30/24 at 2:05 P.M., revealed RCA #41 was terminated on 11/25/24 for contributing to Resident #26's fall from the bed when she left the bed in the highest position.

Interview with RCA #41 on 01/13/25 at 10:55 A.M., revealed Resident #26 was assigned to Agency CNA #40 on 11/11/24. RCA #41 stated she observed Resident #26 sliding out of the Broda chair three times while situated in the common area. RCA #41 stated she repositioned the resident in the Broda chair and prior to the third time she repositioned the resident, she instructed Agency CNA #40 to lay the resident down in her bed, because the resident was going to fall out of the Broda chair. Agency CNA #40 stated she was not going to lay the resident down in bed. RCA #41 instructed Agency CNA #40 it had been normal practice if Resident #26 was leaning over in her Broda chair, the family had requested for the resident to be put in bed. RCA #41 stated she observed the resident in the main lobby leaning over in the Broda with no supervision, so she put her in her room, used a Hoyer lift to put the resident in the bed and the bed was malfunctioning. RCA #41 stated the bed would not go down from the highest position. RCA #41 stated at times, the bed would not go down and Hospice and facility management were aware. RCA #41 stated she transferred the resident to her bed and resumed her tasks without telling anyone about the bed malfunctioning. RCA #41 stated she heard the resident fell from her bed while it was in the highest position.

Interview with Hospice CNA #42 on 01/13/25 at 11:42 A.M., revealed she was in the facility on 11/11/24 when the resident fell from her bed. Hospice CNA #42 stated Resident #26's bed was not broken and the remote had to be pressed a little harder to move the bed up and down.

Interview with Agency CNA #40 on 01/13/25 at 11:51 A.M., revealed she was tasked with caring for Resident #26 on 11/11/24. Agency CNA #40 stated Resident #26 was in her Broda chair in the common area and RCA #41 never mentioned she was going to put the resident back in her bed because she leaning over. Agency CNA #40 stated she entered Resident #26's room and found the resident lying on the floor and her bed was at the highest level. Agency CNA #40 stated the resident had a large hematoma on her head.

Interview with Corporate LPN #38 on 01/13/25 at 12:22 P.M. verified Resident #26 was at risk for falls and the resident had an unwitnessed fall with injuries which included a large hematoma on her head, facial bruising and a left knee abrasion on 11/11/24 when RCA #41 transferred the resident to her bed then left the resident's bed in the highest position and the resident fell from her bed. Corporate LPN #38 stated the facility does not do neurological (neuro) checks since they are not required by their licensure status. Corporate LPN #38 stated the facility utilized a head injury flow sheet which indicates observe the resident for 72 hours and the facility charted by exception.

Observations of Resident #26 on 01/13/25 from 1:15 P.M. through 1:31 P.M., revealed the resident was lying in a Broda chair in the common area with no staff in the area.

Interview with Dining Coordinator (DC) #60 on 01/13/25 at 1:31 P.M., verified Resident #26 was lying in a Broda chair in the dining room and no staff were in the area. DC #60 stated she was delivering food to the new employees and was just passing through the area.

Review of the personnel file for RCA #41, revealed she was placed on suspension pending an investigation into allegations of a resident that had a fall on 11/11/24. On 12/02/24, RCA #41 was terminated from employment.

Review of the job description for a Caregiver dated 04/2019, revealed Caregivers were to provide direct care to residents following an individual service plan, treat each resident with respect and dignity, recognizes individual needs and maintains a clean, safe and orderly environment for residents. The document was signed and dated by RCA #41 on 04/28/22.

Review of facility policy titled Falls Management Policy revised 01/2025, revealed residents had the potential to fall and therefore the facility utilized universal fall precautions to all residents. A fall risk evaluation is completed at the time of move in/admission and per state regulations and a fall is reported to the facility's incident reporting system and residents who sustain a fall should have a post fall evaluation completed to consider possible interventions to reduce the potential for future falls and injury. Resident falls are noted in the resident's record, entered into the incident reporting system, a post fall evaluation is completed after a resident fall with individualized interventions being considered, document the resident's fall/injuries, resident response and interventions taken, service plan is reviewed for fall interventions and updated as necessary, review the fall at the next stand-up meeting, and discuss falls at the next care conference. A head injury flowsheet was to be completed for head injury witnessed, unwitnessed or suspected.

This violation represents non-compliance investigated under Complaint Number OH00160266 and Complaint Number OH00160356.

Based on medical record review, staff interviews, review of facility investigation, review of a facility Self-Reported Incident (SRI), and review of facility policy, the facility failed to conduct thorough investigations to determine the root cause analysis to identify potential hazards, failed to accurately document falls and failed to implement resident-specific interventions to reduce and/or eliminate falls. This affected one (#26) of the three residents reviewed for falls. The facility census was 31.

Findings Include:

Review of the medical record for Resident #26, revealed an admission date of 09/05/23. Diagnoses included, but not limited to, vascular dementia, disturbance, mood disturbance and anxiety, hypertension, cerebral atherosclerosis, aphasia following cerebral infarction, transient cerebral ischemic attack and resident was receiving hospice services.

Review of a Fall Risk Evaluation - Move in and Change in Condition for Resident #26 dated 09/05/23, revealed the resident was listed as a level two fall risk indicating the resident was at risk for falls. The staff were to determine the resident's fall risk based on the responses on the form and the fall level may be increased based on a nurse's clinical judgment.

Review of the incident log from 09/01/24 through 01/13/25, revealed Resident #26 had four recorded falls on the following dates:

a. On 09/06/24 at 6:30 P.M., Resident #26 was seated in a Broda chair in the common area and had an unwitnessed fall out of a Broda chair (chair that provides comfort, support, and mobility). The resident was trying to get out of the chair. The resident was checked for injuries, the emergency contact and the Health and Wellness Director (HWD) were notified. Interventions were increased rounding, change the resident's positions, and to not leave the resident unattended in a Broda chair. There was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

b. On 09/18/24 at 3:00 P.M., Resident #26 was seated in a Broda chain in her room and had an unwitnessed fall out of a Broda chair. Nine-one-one (911) was called, the resident was checked for injuries, and the emergency contact and the HWD was notified. The resident was admitted to the hospital for a urinary tract infection (UTI) and diverticulitis. All scans were completed with no acute fractures. Interventions included to not leave the resident unattended in a Broda chair. There was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

c. On 12/18/24 at 5:55 P.M., Resident #26 was seated in a Broda chair in the common area and had an unwitnessed fall out of a Broda chair. There was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall and there were no documented interventions to reduce and/or eliminate falls.

. On 12/18/24 at 6:45 P.M., Resident #26 was seated in a Broda chair in the common area and had an unwitnessed fall from a Broda chair. There was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall and there were no documented interventions to reduce and/or eliminate falls.

There was no documentation on the incident log to include falls on 09/15/24, 09/16/24 and 10/09/24. The resident had additional unwitnessed falls on 09/06/24, 09/18/24, 11/11/24 and two on 12/18/24.

Review of a Post Fall note for Resident #26 dated 09/06/24 at 6:44 P.M. and authored by Licensed Practical Nurse (LPN) #37, revealed the resident had an unwitnessed fall from a Broda chair while seated in the common area. The resident was agitated and was trying to get out of the Broda chair when LPN #37 repositioned the resident in the chair and an aide took the resident to her room to get ready for bed. The comments section indicated the resident slid her bottom onto the footrest causing the chair to tip over causing the resident to fall out of the chair. There were no signs of an injury from the fall. The provider and resident's representative were contacted. Interventions were increased rounding, change the resident's positions, and to not leave the resident unattended in a Broda chair There was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a nurse progress note for Resident #26 dated 09/15/24, revealed no documentation related to the resident's fall, an investigation completed for the fall and no documented interventions to reduce and/or eliminate falls.

Review of a nurse progress note for Resident #26 dated 09/16/24, revealed no documentation related to the residents fall, an investigation for the fall and no documented interventions to reduce and/or eliminate falls.

Review of a Post Fall note for Resident #26 dated 09/18/24 at 3:45 P.M. and authored by LPN #37, revealed resident had an unwitnessed fall in her room next to a chair and the resident went to the emergency room due to hitting her head and complaining of back pain. The resident's representative was contacted and was going to meet the resident at the hospital. Interventions included to not leave resident unattended in Broda chair. There was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a nurse progress note for Resident #26 dated 10/09/24, revealed no documentation related to the residents fall, an investigation being completed for the fall and no documented interventions to reduce and/or eliminate falls.

Review of the Personal Service Plan for Resident #26 dated 11/08/24, revealed the resident had difficulty in communicating needs and preferences, was not always oriented to person, place or time, the resident displayed anxious, disruptive or obsessive behaviors, and universal fall precautions included the resident's bed should be kept locked and in its lowest position when the resident was resting in bed. Resident #26 was noted to be found on the floor on 09/15/24, 09/16/24 and 10/09/24 with no injuries. Resident #26 was a two-person assist for all transfers and required a mechanical lift (Hoyer) for all transfers.

Review of a Post Fall note for Resident #26 dated 12/18/24 at 6:45 P.M. and authored by LPN #37, revealed the resident had an unwitnessed fall out of a geriatric (Geri) chair while in the common area. The resident fell on the front of her upper body and head with no physical signs of head injury and no signs of skin injury. The health care provider and Hospice were contacted regarding the fall. Hospice said they would brainstorm ideas for the chair because when the resident puts weight on the footrest, the chair flips over. There was no documented evidence of any interventions being implemented to reduce and/or eliminate falls and there was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a Post Fall note for Resident #26 dated 12/19/24 at 11:33 A.M. (a late entry) and authored by LPN #37, revealed the resident had an unwitnessed fall from the chair in the common area on 12/18/24 at 5:57 P.M. The resident was noted to be sitting in the common area due to excessive anxiety and the resident was trying to climb out of the chair. The resident was given an as needed (PRN) Ativan (medication for anxiety) just prior to the fall. The resident lunged forward, and the chair tipped forward and the resident fell on her upper body and face with no physical signs of injuries. The POA was made aware, and Hospice was called. There was no documented evidence of any interventions being implemented to reduce and/or eliminate falls and there was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Interview with Corporate LPN #38 on 01/13/25 at 12:22 P.M., verified Resident #26 was at risk for falls and had unwitnessed falls on 09/06/24, 09/15/24, 09/16/24, 09/18/24, 10/09/24, and two on 12/18/24. Corporate LPN #38 verified the falls on 09/15/24, 09/16/24, and 10/09/24 were not included on the incident log, there were no nurse's progress notes, no investigations to determine a root cause analysis and no interventions being implemented to reduce and/or eliminate falls. Corporate LPN #38 verified Resident #26's Personal Service Plan indicated resident was found on the floor on 09/15/24, 09/16/24, and 10/09/24; however, there was no additional documentation about the falls. Corporate LPN #38 verified Resident #26 had unwitnessed falls from a Broda chair while situated in the common area on 09/06/24 and 09/18/24 and interventions included not to leave the resident unattended in Broda chair. Corporate LPN #38 verified Resident #26 had additional unwitnessed falls from a Broda chair while situated in the common area on 12/18/24 at 5:55 P.M. and again on 12/18/24 at 6:45 P.M. Corporate LPN #38 verified there was no documented evidence of any interventions being implemented to reduce and/or eliminate falls when the resident had two falls 12/18/24. Additionally, Corporate LPN #38 verified there was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's falls on 09/06/24, 09/18/24, and the two falls on 12/18/24. Corporate LPN #38 stated the facility does not do one-on-one (1:1) monitoring, but the residents' families had the right to hire someone or do it themselves.

Interview with LPN #37 on 01/13/25 at 5:04 P.M., verified Resident #26 had two unwitnessed falls on 12/18/24 when the resident tipped her Broda chair forward. LPN #37 stated she notified Hospice to have them brainstorm ways to keep the chair from tipping over. LPN #37 verified the resident had previous falls from a Broda chair on 09/06/24 and 09/18/24 and the interventions to prevent future falls was to not leave the resident unattended in a Broda chair.

Review of facility policy titled Fall Interventions revised 02/2024, revealed the fall interventions may be increased in level two falls based on the nurses' clinical judgment. Additional interventions to consider include reviewing the resident's medications, pain levels, encourage a program to increase observation and fall interventions not listed or those requested by the family will be consider. A post-fall evaluation is completed after a resident fall and individualized interventions are considered. The post-fall evaluation form is a part of the resident records. The best practices include an evaluation of the residents and any injuries that require immediate treatment, initial evaluation is completed by the first associate on the scene, a secondary evaluation is completed by the HWD or nurse, after reviewing the current fall, the HWD should review the resident's history of falls and identify any trends, and interventions identified are implemented, and documented in the resident record and on the personal service plan.

Review of facility policy titled Falls Management Policy revised 01/2025, revealed residents had the potential to fall and therefore, the facility utilized universal fall precautions for all residents. A fall risk evaluation is completed at the time of move in/admission and per state regulations and a fall is reported to the facility's incident reporting system and residents who sustain a fall, should have a post-fall evaluation completed to consider possible interventions to reduce the potential for future falls and injury. Resident falls are noted in the resident's record, entered into the incident reporting system, a post-fall evaluation is completed after a resident fall with individualized interventions being considered, document the resident's fall/injuries, resident response and the interventions taken, the service plan is reviewed for fall interventions and updated as necessary, review the fall at the next stand-up meeting, and discuss falls at the next care conference. A head injury flowsheet was to be completed for a head injury witnessed, unwitnessed or suspected.

This violation represents non-compliance investigated under Complaint Number OH00160266 and Complaint Number OH00160356.

Based on review of the Enhanced Information Dissemination and Collection (EIDC) system, review of facility documents and staff interview, the facility failed to ensure the infection prevention and control designee's name and contact information including electronic mail address was updated on the electronic system prescribed by the director no later than ten days after appointing an individual or no later than ten days after the designated individual was replaced. This had the potential to affect all 40 residents residing in the facility. The facility census was 40.

Findings include:

Review of the EIDC system on 10/15/24 at 3:22 P.M. revealed Former Health and Wellness Director (HWD) #800 was listed as the infection control coordinator.

Review of the facility's undated employee contact list revealed the facility did not currently have a HWD and Former HWD #800 was not listed on the employee contact list.

Interview with Corporate Executive Director #500 on 10/15/24 at 3:30 P.M. verified Former HWD #800 was no longer employed by the facility and her last day at the facility was 09/25/24. Corporate Executive Director #500 stated Area HWD #850 took over as the infection prevention and control designee on 09/25/24. Corporate Executive Director #500 verified the facility did not update EIDC with Area HWD #850's information and the EIDC system still contained Former HWD #800's name and contact information.

Based on observation, staff interview and policy review, the facility failed to ensure the windowsill in the kitchen was clean and free from debris. This had the potential to affect all 40 residents residing in the facility. The facility census was 40.

Findings include:

Observation of the facility on 10/15/24 at 8:18 A.M. revealed there was gray debris and a large fly in a vase on the windowsill in the kitchen. There was also an air conditioner in the window that was blowing on the windowsill towards the preparation table and stove.

Interview with Dietary Services Coordinator (DSC) #25 on 10/15/24 at 3:30 P.M. verified there were gray debris and a large fly in a vase on the windowsill in the kitchen. DSC #25 also confirmed there was an air conditioner in the window that was blowing on the windowsill towards the preparation table and stove.

Review of the facility's kitchen cleaning policy dated July 2024 revealed all kitchens and food preparation areas must be cleaned according to federal, state and local regulations.