Brookdale Mount Vernon

Based on interview and medical record review the facility failed to ensure Resident #14's medication list was kept up to date when provided to a hospital. This affected one resident (#14) of three residents reviewed for hospitalizations. The facility census was 51.

Findings include:

Review of Resident #14's medical record revealed an admission date of 10/29/25 with diagnoses including major depressive disorder, suicidal ideations, and Alzheimer's disease.

Review of Resident #14's Brief Interview of Mental Status (BIMS) revealed the resident had impaired cognition.

Review of Resident #14's physician orders revealed he was on Aricept (donepezil) 10 milligrams (mg) from 02/04/26 to 02/26/26. On 02/27/26 Galanatamine Hydrobromide four mg was started one time a day.

Review of Resident #14's medical record revealed he was transferred to the hospital on 03/21/26.

Review of Resident #14's hospital paperwork from 03/21/26 to 03/24/26 revealed an order summary report from the facility dated 02/26/26. This summary indicated the resident was on Aricept two tablets one time a day for dementia. The physician assessment and plan revealed the daughter was concerned about a medication the resident was on at the facility for behaviors. The physician reviewed the medication list they had been provided and the daughter reported it was incorrect. After speaking to Licensed Practical Nurse (LPN) #165, it was revealed the resident was no longer on Aricept and had started Galantamine Hydrobromide.

Interview on 04/06/26 at 3:11 P.M. with Nurse Practitioner #175 revealed in February she had discontinued Resident #14's Aricept per the daughter's request. The daughter felt this medication was contributing to increased confusion. Nurse Practitioner #175 felt the resident was experiencing a normal progression of his disease, however, she agreed to discontinuing the medication.

Interview on 04/07/26 at 8:25 A.M. with LPN #165 revealed the facility did not always have a nurse at night. Due to this they had pre-printed packets for the resident care assistants (RCA) in case someone had to be sent to the hospital. This included a medication list that was preprinted once a month. LPN #165 revealed Resident #14's fall occurred at night, so an RCA sent this preprinted medication list to the hospital with him and it was not up to date with his current orders.

This violation represents noncompliance investigated under complaint OH00170246.

Based on medical record review, interview, and review of facility policy, the facility failed to thoroughly investigate Resident #14's fall. This affected one resident (#14) of three residents reviewed for falls. The facility census was 51.

Findings include:

Review of Resident #14's medical record revealed an admission date of 10/29/25 with diagnoses including major depressive disorder, suicidal ideations, and Alzheimer's disease.

Review of Resident #14's Brief Interview of Mental Status (BIMS) revealed the resident had impaired cognition.

Review of Resident #14's progress note dated 03/21/25 at 9:15 P.M. revealed the resident had a fall in his room. The resident did not state what he was trying to do. Resident Care Assistant (RCA) #171 heard a noise when walking past Resident #14's room and found him on the floor. He was unable to bear weight on his left leg.

Interview on 04/06/26 at 2:32 P.M. with the Health and Wellness Director revealed she had no further documentation related to his fall. She could not identify what interventions were in place, when the resident was last seen, or where in the room he was found.

Review of the policy 'Fall Management and Recovery Policy' revised March 2026, revealed the fall, resident response, and interventions were to be documented in the progress notes and a post fall evaluation was to be completed.

This violation represents noncompliance investigated under complaint OH00170246.

Based on record review and staff interview, the facility failed to ensure all staff were checked against the nurse aide registry for a history of abuse, neglect, or exploitation. This had the potential to affect all residents residing in the facility. The facility census was 53.

Findings include:

Review of the personnel file for Dining Services Staff #10 revealed a hire date of 05/07/25. The personnel file did not include documentation or verification that the facility had checked the nurse aide registry for a history of abuse, neglect, or exploitation for Dining Services Staff #10.

Interview on 02/03/26 at 10:35 A.M. with Business Office Manager (BOM) #20 confirmed the facility had no documentation of checking the nurse aide registry for a history of abuse, neglect, or exploitation upon hire for Dining Services Staff #10.

Based on observation, interview, and facility policy review, the facility failed to ensure medications were labeled and expired medications were appropriately discarded. This affected two Residents (#22 and #34) of 53 residents reviewed for medication storage. The facility census was 53.

Findings include:

1. Observation on 02/03/26 at 9:05 A.M. of the medication cart labeled C-Cart revealed the cart contained the following medication concerns for Resident #34: One bottle of Timolol (an eye drop commonly used to treat glaucoma) 0.5% bottle with no date open and a dispense date from the pharmacy of 09/03/25; One open bottle of Timolol 0.5% bottle with no open date and a dispense date from the pharmacy of 12/01/25; one open bottle of Latanoprost (an eye drop commonly used to treat glaucoma) 0.005% with no date open and a dispense date of 09/13/25; an open bottle of Timolol 0.5% eye drops with an expiration date of December 2022; and one open bottle of Travoprost (an eye drop commonly used to treat glaucoma) 0.004% which was undated and was dispensed by the pharmacy on 09/03/25.

2. Observation on 02/03/26 at 9:15 A.M. of the medication cart labeled A-Cart revealed the cart contained one unopened, expired bottle of Clearlax (laxative) supplement labeled stock supply which expired in August 2025.

3. Observation on 02/03/26 at 9:25 A.M. of the medication cart labeled B-Cart revealed the cart contained the following medication concerns for Resident #22: One open bottle of a prescription cough syrup Bromphen PSE DM (brompheniramine/pseudoephedrine/dextromethorphan) 2-30-10 milligrams / 5 milliliter cough syrup with a dispense date of 04/17/24 and an expiration date of 04/17/25.

Interview on 02/03/26 at 9:30 A.M. with the Licensed Practical Nurse (LPN) #11 verified the medications were expired and the eye drops were not dated when opened.

Review of the facility policy titled Medication and Treatment-General Guidelines for Medication Administration revised September 2025 revealed topical medications, eye drops, bottles, inhalers, insulin vials/pens, should be dated when opened .

Based on record review, staff interview, review of facility policy, and review of the facility Tuberculosis (TB) risk assessment, the facility failed to ensure employees had annual TB screenings completed. This had the potential to affect all residents residing in the facility. The facility census was 53.

Findings include:

Review of the personnel file for Licensed Practical Nurse (LPN) #11 revealed a hire date of 03/12/24. Continued review of the personnel file revealed the last TB screening was completed on 01/02/25.

Review of the personnel file for Administrative Assistant #14 revealed a hire date of 02/22/22. Continued review of the personnel file revealed the last TB screening was completed on 01/02/25.

Review of the personnel file for the Executive Director (ED) revealed a hire date of 07/27/06. Continued review of the personnel file revealed the last TB screening was completed on 01/02/25.

Interview on 02/03/26 at 12:30 P.M. with Business Office Manager (BOM) #20 confirmed the facility had not completed an annual TB screening for LPN #11, Administrative Assistant #14, or the ED.

Review of the facility policy titled Tuberculosis Control Plan last revised 12/2022 revealed a TB Surveillance Questionnaire will be completed annually.

Based on observation, staff interview, and facility policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. Additionally, the facility failed to ensure food was appropriately stored and dated. This had the potential to affect all residents residing in the facility. The facility census was 53.

Findings include:

Observation of the kitchen on 02/03/26 at 11:15 A.M. revealed:

Two open loaves of bread with no date open with an expiration date of 12/17/25.

Two packs of hamburger buns with an expiration date of 12/17/25.

One opened pack of hamburger buns with no open date listed.

Continued observation of the kitchen on 02/03/26 revealed the floor area underneath the clean dishes and serving/preparation area was dirty with several food remnants, including french fries and a chicken tender.

Interview with Business Office Manger (BOM) #20 and Dietary Services #21 on 02/03/26 at 11:20 A.M. verified the open bread, undated items, and expiration dates. BOM #20 stated when they get bread products in, they are kept frozen, but BOM #20 was unable to recall open dates.

Review of facility policy titled Food Storage revised 06/2024 revealed all foods stored sould be dated when it is placed in the storeroom, refrigerator or freezer.

This violation is a recite to the annual survey completed 02/27/25.

Based on observations, staff interview and facility policy review, the facility failed to ensure food was stored in a manner that protects it against contamination and spoilage. This has the potential to affect all 46 residents residing in the facility. Findings include: Observation on 02/27/25 at 9:30 A.M. in kitchen revealed the following: A large bag of panko breadcrumbs was found on the floor and open to air. Large bags of flour were open to air. A bag of couscous was found to be opened, re-sealed, with no opened-on date. The refrigerator was found to have one opened and undated package of pre-sliced sandwich cheese. The refrigerator was found to have one opened and undated bag of shredded cheese. Interview on 02/27/25 with CB Activities Coordinator #28 confirmed these findings at the time of discovery. Review of the facility policy titled Safety and SanitationBased on observations, staff interview and facility policy review, the facility failed to ensure food was stored in a manner that protects it against contamination and spoilage. This has the potential to affect all 46 residents residing in the facility.

Findings include:

Observation on 02/27/25 at 9:30 A.M. in kitchen revealed the following:

A large bag of panko breadcrumbs was found on the floor and open to air.

Large bags of flour were open to air.

A bag of couscous was found to be opened, re-sealed, with no opened-on date.

The refrigerator was found to have one opened and undated package of pre-sliced sandwich cheese.

The refrigerator was found to have one opened and undated bag of shredded cheese.

Interview on 02/27/25 with CB Activities Coordinator #28 confirmed these findings at the time of discovery.

Review of the facility policy titled Safety and Sanitation