Inspection Reports for Brookwood Retirement Community
12100 Reed Hartman Hwy, Cincinnati, OH 45241, United States, OH, 45241
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
106 residents
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 2
Date: Nov 27, 2024
Visit Reason
The inspection was conducted as a complaint investigation to assess the facility's compliance with privacy of residents' personal and medical records and adequacy of care related to activities of daily living, specifically nail care.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00158680.
Findings
The facility failed to ensure residents' private care information was not posted in public areas, affecting 14 of 16 residents reviewed for privacy. Additionally, the facility failed to provide adequate nail care to one resident reviewed for activities of daily living.
Deficiencies (2)
Failed to keep residents' personal and medical records private and confidential, with information posted in public areas visible to others.
Failed to provide adequate nail care to a resident unable to perform activities of daily living, with no documented evidence of nail care offered or provided.
Report Facts
Residents affected: 14
Residents reviewed for privacy: 16
Facility census: 106
Residents affected: 1
Residents reviewed for ADLs: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #226 | Stated papers were always displayed on the wall for nurse aides to know care due for residents | |
| Licensed Practical Nurse (LPN) #242 | Verified documents posted in public area displayed resident names, room numbers, and clinical and personal information | |
| Licensed Practical Nurse (LPN) #250 | Verified Resident #15's fingernails on left hand were sharp and needed trimming | |
| Corporate Registered Nurse (RN) #55 | Verified no documented evidence that fingernail care was offered or provided to Resident #15 |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 2
Date: Jun 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00154222, focusing on allegations of resident privacy violations and failure to provide timely incontinence care.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00154222.
Findings
The facility failed to maintain resident privacy when an employee took and shared a photo of a resident without consent, and failed to provide timely incontinence care to a resident dependent on staff. Both deficiencies were found to affect one resident each among those reviewed.
Deficiencies (2)
Failed to maintain resident privacy when an employee took a photo of a resident without permission and shared it via text message.
Failed to provide timely incontinence care to a resident dependent on staff for incontinence care.
Report Facts
Residents reviewed for privacy: 4
Residents affected for privacy deficiency: 1
Residents reviewed for incontinence care: 4
Residents affected for incontinence care deficiency: 1
Facility census: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #301 | State Tested Nurse Assistant | Interviewed regarding the unauthorized photo of Resident #150 |
| STNA #352 | State Tested Nurse Assistant | Identified as the employee who took and shared the unauthorized photo of Resident #150 |
| STNA #336 | State Tested Nurse Assistant | Interviewed and observed providing incontinence care to Resident #78 |
| STNA #340 | State Tested Nurse Assistant | Interviewed and observed providing incontinence care to Resident #78 |
Inspection Report
Routine
Census: 108
Deficiencies: 5
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, notification procedures, care planning, meal service hygiene, and facility accommodations.
Findings
The facility was found deficient in ensuring residents had access to call lights, notifying the Ombudsman of hospital discharges, conducting quarterly care conferences, delivering meals hygienically, and providing suitable furniture in resident rooms. These deficiencies affected multiple residents with minimal harm or potential for actual harm.
Deficiencies (5)
Failed to ensure residents had access to call lights, affecting one resident (Resident #20).
Failed to notify the Ombudsman when residents were discharged to the hospital, affecting one resident (#33).
Failed to ensure residents received quarterly care conferences, affecting four residents (#20, #70, #74, #59).
Failed to ensure resident meal trays were delivered in a hygienic manner, affecting four residents (#61, #06, #77, #79).
Failed to provide furniture suitable for the comfort of residents and/or visitors, affecting one resident (#29).
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 4
Residents affected: 1
Residents sampled for call lights: 32
Residents observed for dining service: 24
Facility census: 108
Hospitalizations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director #116 | Did not ensure Resident #20 had access to call light | |
| Maintenance Staff #16 | Did not notice or address call light access issue for Resident #20 | |
| State Tested Nursing Assistant (STNA) #115 | Did not ensure Resident #20 had access to call light after delivering lunch tray | |
| State Tested Nursing Assistant (STNA) #08 | Did not return to check on Resident #20 after being alerted | |
| State Tested Nursing Assistant (STNA) #151 | Did not ensure Resident #20 had access to call light before leaving room | |
| Activities Staff #117 | Did not ensure Resident #20 had access to call light after informing about activities | |
| Licensed Practical Nurse (LPN) #29 | Confirmed Resident #20's call light was not within reach and verbalized policy | |
| Social Service Director (SSD) #51 | Verified Ombudsman was not notified for Resident #33 hospital discharges and care conference issues | |
| Social Worker #10 | Verified care conference deficiencies for multiple residents | |
| State Tested Nursing Assistant (STNA) #152 | Delivered meal trays without changing gloves or performing hand hygiene | |
| Administrator | Verified Resident #29 did not have a chair in room and was unaware |
Inspection Report
Routine
Census: 125
Deficiencies: 16
Date: Oct 31, 2019
Visit Reason
Routine inspection of Brookwood Retirement Community to assess compliance with regulatory requirements including resident transfer/discharge notifications, care planning, medication administration, wound care, dietary services, and facility operations.
Findings
The facility failed to provide timely notification to the Long-Term Care Ombudsman of resident transfers and discharges, failed to provide written bed hold notices to residents and their representatives, failed to provide residents with a summary of baseline care plans, failed to implement care plans regarding splint use, failed to complete wound treatments as ordered, failed to provide timely podiatry services, failed to ensure fall prevention interventions were in place, failed to accurately complete dialysis flowsheets, failed to post daily nurse staffing data, failed to ensure controlled substances were counted at shift changes, failed to properly label and store medications, failed to follow planned menus, and failed to ensure proper sanitation of food service equipment.
Deficiencies (16)
Failed to provide timely notification of resident transfers/discharges to the Long-Term Care Ombudsman affecting eight residents.
Failed to provide written bed hold notices to residents and their representatives upon transfer/discharge affecting four residents.
Failed to provide residents and their representatives with a summary of the baseline care plan affecting ten residents.
Failed to implement care plan interventions for splint use for Resident #102; splints not used as ordered and documentation incomplete.
Failed to complete diabetic ulcer and surgical wound treatments as ordered for Resident #113; treatments missed on multiple dates.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #113; unstageable pressure ulcers present and treatments incomplete.
Failed to ensure timely podiatry services for Resident #11 with excessively long toenails and no documented podiatry visits.
Failed to provide appropriate care to maintain and/or improve range of motion for Resident #102; splints not used and documentation incomplete.
Failed to ensure fall prevention interventions were in place for Resident #54; non-skid strips ordered but not in place at time of observation.
Failed to ensure peritoneal dialysis flowsheets were accurately completed and weights/vital signs obtained for Resident #72 on multiple dates.
Failed to post nurse staffing data on a daily basis; last posted data was two days old.
Failed to ensure controlled substances were counted at the end of each shift; missing documentation and signatures for multiple dates.
Failed to ensure medications were properly labeled and stored; insulin vials and pens not labeled correctly, eye drops opened and not dated, and refrigerated medications not stored properly.
Failed to ensure planned menus approved by the Registered Dietitian were followed; missing menu items served on the secured dementia unit.
Failed to ensure food was stored and prepared under sanitary conditions and that dishwashing equipment was properly sanitized; food items undated or past use-by dates, microwave heavily soiled, and dishwashing machine sanitizer not dispensing properly.
Failed to ensure medication error rate was below 5%; observed medication administration errors including improper timing of eye drops and incorrect administration of crushed medications via gastric tube.
Report Facts
Facility census: 125
Medication administration observed: 26
Medication administration errors: 10
Medication error rate: 38.46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #143 | Registered Nurse | Documented resident behaviors and hospital transfer for Resident #91 |
| LSW #179 | Licensed Social Worker | Documented psychiatric hospital transfer and lack of discharge notice for Resident #91 |
| RN #153 | Registered Nurse | Documented Resident #1's admission and hospital transfer |
| RN #34 | Registered Nurse | Documented emergency transfer of Resident #122 |
| Administrator | Reported lack of notification to LTC Ombudsman for resident transfers/discharges | |
| DON | Director of Nursing | Unable to provide documentation of required notices and bed hold information for multiple residents |
| STNA #74 | State Tested Nurse Aide | Interviewed regarding Resident #102's splint use |
| LPN #139 | Licensed Practical Nurse | Unit manager aware of missing splint use documentation for Resident #102 |
| TM #305 | Certified Occupational Therapy Assistant, Therapy Manager | Provided physical therapy discharge summary for Resident #102 |
| RN #163 | Registered Nurse | Reported wound treatments and splint use for Resident #113 |
| APRN #300 | Advanced Practice Registered Nurse | Observed wound treatments and assessed pressure ulcers for Resident #113 |
| LPN #27 | Licensed Practical Nurse | Observed unlabeled eye drops on medication cart |
| RD LD #446 | Registered Licensed Dietitian | Observed meal service and confirmed missing menu items |
| DS #33 | Dietary Staff | Observed dishwashing and reported sanitizer pump not working |
| DCS #301 | Director of Clinical Service | Reported dishwashing machine issues and repair |
| LPN #44 | Licensed Practical Nurse | Observed medication cart controlled substances count missing documentation |
| LPN unit manager #126 | Licensed Practical Nurse Unit Manager | Verified controlled substances count issues and medication cart security |
| LPN #212 | Licensed Practical Nurse | Observed medication administration errors with eye drops |
| RN #119 | Registered Nurse | Observed medication administration errors with crushed medications via gastric tube |
| STNA #191 | State Tested Nurse Aide | Observed meal service on Diamond unit |
| STNA #67 | State Tested Nurse Aide | Observed meal service on Diamond unit |
| LPN #139 | Licensed Practical Nurse | Observed resident's toenails and reported history of podiatry refusal |
| LSW #179 | Licensed Social Worker | Reported resident consented to podiatry after long toenails noted |
| STNA #115 | State Tested Nurse Aide | Reported responsibility for fingernail clipping but not toenails |
| RDLD #500 | Registered Licensed Dietician | Reported communication with renal dietician and dialysis weight monitoring |
| RNUM #168 | Registered Nurse Unit Manager | Reported dialysis flowsheet issues and missing fall prevention intervention |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 9
Date: Sep 20, 2018
Visit Reason
The inspection was conducted based on complaints alleging failure to accurately document resident code status, failure to investigate abuse allegations, failure to notify residents of bed hold policies upon hospital transfer, failure to provide appropriate activities, failure to monitor and treat edema, failure to investigate falls, failure to provide proper catheter care, failure to store food safely, and failure to implement infection prevention and control.
Complaint Details
Complaint Number OH00099742 substantiated related to failure to investigate a resident fall and implement interventions.
Findings
The facility was found deficient in multiple areas including inconsistent documentation of resident code status, failure to investigate and report abuse allegations timely, failure to notify residents or representatives of bed hold policies upon hospital transfer, failure to provide individualized activities, failure to monitor and treat edema as ordered, failure to investigate a resident fall and implement interventions, failure to provide proper catheter care and discontinue catheter as ordered, failure to date opened foods in refrigerators, and failure to properly clean blood glucose monitors and follow isolation precautions.
Deficiencies (9)
Failed to ensure a resident's code status was documented accurately and consistently between the electronic health record and the hard chart.
Failed to implement abuse policy to investigate an allegation of abuse and failed to timely report suspected abuse to the State Agency.
Failed to notify the resident or the resident’s representative in writing of the facility bed hold policy upon transfer to the hospital.
Failed to ensure residents received individual and group activities to meet their needs.
Failed to ensure a resident's edema was monitored and treated as ordered.
Failed to ensure a fall was investigated, interventions were implemented and monitored for effectiveness.
Failed to ensure a resident received proper catheter care and a catheter was discontinued as ordered.
Failed to store foods in a safe manner by not dating opened foods.
Failed to ensure proper cleaning of a blood glucose monitor used for multiple residents and failed to ensure staff were knowledgeable of isolation precautions.
Report Facts
Facility census: 117
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 114
Residents affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #23 | Licensed Practical Nurse | Unable to determine resident's correct code status from DNR form |
| ADON #136 | Assistant Director of Nursing | Unable to determine resident's correct code status from DNR form |
| RNS #192 | Registered Nurse Supervisor | Interviewed regarding abuse allegation and fall of Resident #85 |
| RNADON #124 | Registered Nurse Assistant Director of Nursing | Interviewed regarding abuse allegation and fall of Resident #85; questioned resident about incident |
| STNA #74 | State Tested Nursing Assistant | Reported being informed of Resident #85 fall and abuse allegation |
| DON | Director of Nursing | Reported Resident #85 did not have any falls at the facility; verified failure to notify residents of bed hold policy |
| LPN #510 | Licensed Practical Nurse | Confirmed Resident #262 did not have ace wraps in place as ordered |
| LPN #78 | Licensed Practical Nurse | Performed blood glucose monitoring; unaware of manufacturer cleaning instructions |
| Dietary Manager #150 | Dietary Manager | Verified undated and opened foods in refrigerators |
| Activity Assistant #122 | Activity Assistant | Did not invite Resident #47 to karaoke music activity |
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