Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and policy review, the facility failed to ensure residents had access to call lights. This
affected one resident (Resident #20) of the 32 residents sampled for call lights. The facility census was 108.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #20 revealed the resident was admitted to the facility on [DATE].
Diagnoses included unspecified dementia; hemiplegia/hemiparesis following nontraumatic subarachnoid
hemorrhage affecting left non-dominant side; contracture to left wrist, left hand, and left knee; Chronic
Obstructive Pulmonary Disease (COPD); and psychotic disorder with delusions related to a known
physiological condition.
Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 09/21/23 for Resident #20,
revealed the resident had moderately impaired cognition, had verbal behaviors, did not wander, and
occasionally rejected care.
Observation of Resident #20 on 10/25/23 at 9:16 A.M., revealed the resident lying in bed with eyes closed.
The call light was draped across the nightstand and was not within the resident's reach.
Observation of Resident #20 on 10/25/23 at 9:29 A.M., revealed Activities Director #116 entered the
resident's room with Surveyor to find the October activities calendar on the top of the dresser top, and did
not notice or check to ensure Resident #20 had access to her call light.
Observation of Resident #20's room on 10/25/23 at 9:45 A.M., revealed Maintenance Staff #16 verified the
wall was torn up due to the bed scraping against the wall. Maintenance Staff #16 stated he was not aware
of the damage and stated he would fix it. Resident #20 laid in bed with her eyes closed with the call light
located on the nightstand and out of the resident's reach. Maintenance Staff #16 did not notice or address
that the resident did not have access to the call light.
Observation of Resident #20 on 10/25/23 at 12:25 P.M., revealed the resident was lying on her back with
eyes closed and was mouth breathing. The call light remained draped over the side of the nightstand and
was not within the resident's reach. The damage to the wall had been spackled over.
Observation of Resident #20 on 10/25/23 at 12:34 P.M., revealed State Tested Nursing Assistant (STNA)
#115 knocked on the resident's door, delivered, and set up Resident #20's lunch tray. STNA #115 left the
resident's room without ensuring Resident #20 had access to her call light.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
365712
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365712
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookwood Retirement Community
12100 Reed Hartman Highway
Cincinnati, OH 45241
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Observation of Resident #20 on 10/25/23 at 12:41 P.M. revealed the resident was tapping her spoon on her
bedside table. This Surveyor alerted STNA #08 that Resident #20 needed assistance. STNA #08 stated Oh
she does that sometimes when she doesn't like her food. STNA #08 briefly looked into the resident's room
from the hallway and continued to deliver meal trays on the hallway. STNA #08 did not return to check on
Resident #20.
Residents Affected - Few
Observation of Resident #20 on 10/25/23 at 12:45 P.M. revealed this Surveyor alerted STNA #151 that
Resident #20 had dropped her spoon on the floor. STNA #151 gave the resident a new spoon. Resident
#20 stated she did not want her food anymore and asked the STNA if she could have a Coke. STNA #151
took the insulated lid from the nightstand, covered the food on the tray, and left the room with the tray.
Resident #20's call light was observed to be draped over the nightstand and was not within reach of the
resident. STNA #151 did not ensure Resident #20 had access to her call light before leaving the room.
Observation of Resident #20 on 10/25/23 at 1:54 P.M. revealed Activities Staff #117 informed Resident #20
of the afternoon activities, answered the resident's questions, and left room without ensuring resident had
her call light. Resident #20's bed was visible from hallway, and the call light was not visible or within the
resident's reach.
Observation and interview with Licensed Practical Nurse (LPN) #29 on 10/25/23 at 2:11 P.M. confirmed
Resident #20's call light was on nightstand and was not within the resident's reach. LPN #29 verbalized
policy and stated the staff were to ensure the residents had access to their call lights before leaving the
resident's room.
Review of policy titled Call Light Policy & Procedure dated 11/2022 revealed residents will have a means to
contact staff directly when in their rooms.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365712
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365712
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookwood Retirement Community
12100 Reed Hartman Highway
Cincinnati, OH 45241
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interviews, the facility failed to ensure the Ombudsman was notified when residents
were discharged to the hospital. This affected one (#33) out of three residents reviewed for discharges. The
facility census was 108.
Findings include:
Review of the record review for Resident #33, revealed the resident was admitted on [DATE]. Diagnoses
included chronic obstructive pulmonary disease (COPD), pressure ulcer of right heel, functional
quadriplegia, atrial fibrillation, epilepsy, and peripheral vascular disease (PVD).
Review of the admission Minimum Data Set (MDS) assessment 3.0 dated 07/21/23 for Resident #33,
revealed the resident was not able to complete a Brief Interview for Mental Status (BIMS) and a score of 99
was assessed which indicated severe cognitive impairment.
Review of the medical chart for Resident #33 revealed the resident was hospitalized four different times
between July and August 2023 with no documented evidence the Ombudsman was notified.
Interview on 10/26/23 at 9:17 A.M. with the Social Service director (SSD) #51 verified the Ombudsman was
not notified when Resident #33 was discharged to the hospital.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365712
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365712
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookwood Retirement Community
12100 Reed Hartman Highway
Cincinnati, OH 45241
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff and resident interviews, and policy review, the facility failed to ensure residents received
quarterly care conferences. This affected four (#20, #70, #74 and #59) of thirty two residents sampled for
care planning. The facility census was 108.
Findings include:
1) Review of the medical record for Resident # 20 revealed the resident was admitted to the facility on
[DATE] and had diagnoses including unspecified dementia, hemiplegia/hemiparesis following nontraumatic
subarachnoid hemorrhage affecting left non-dominant side, chronic obstructive pulmonary disease (COPD)
and psychotic disorder with delusions. Further review of the medical record revealed Resident #20's last
documented care conference was held on 06/28/23.
Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 09/21/23 for Resident #20,
revealed the resident had moderately impaired cognition.
Interview with Resident #20 on 10/24/23 at 10:09 A.M. revealed the resident's brother was her guardian
and she did not remember having any care conferences.
Interview with Social Worker #10 and Social Services Director (SSD) #51 on 10/26/23 at 9:09 A.M. verified
Resident #20's last recorded care conference was 06/28/23 and the resident did not have a care
conference during the third quarter (July, August, September 2023). SSD #51 indicated care conferences
were to be held quarterly.
2) Review of the medical record for Resident # 70 revealed the resident was admitted to the facility on
[DATE] with diagnoses including Parkinson's disease, diabetes mellitus and chronic kidney disease. Further
review of the medical record revealed Resident # 70's last documented care conference was dated
03/23/23.
Review of the most recent MDS assessment dated [DATE] for Resident # 70, revealed the resident had
moderately impaired cognition.
Interview with Resident #70 on 10/23/23 at 11:55 A.M., revealed the resident did not remember having any
care conferences.
Interview with Social Worker #10 and SSD # 51 on 10/26/23 at 9:16 A.M., verified Resident #70's last care
conference was on 03/23/23 and should be done quarterly.
3) Review of the medical record for Resident #74 revealed the resident was admitted to the facility on
[DATE] and had diagnoses including diabetes mellitus, atherosclerotic heart disease, dysarthria following
unspecified cerebrovascular disease, and COPD. Further review of the medical record revealed the
resident's last care conference was dated 09/20/22.
Review of the most recent MDS assessment dated [DATE] for Resident # 74, revealed the resident had
moderately impaired cognition.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365712
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365712
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookwood Retirement Community
12100 Reed Hartman Highway
Cincinnati, OH 45241
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Interview with Resident #74 on 10/23/23 at 12:21 P.M., revealed the resident stated he did not receive care
conferences.
Interview with SSD #51 and Social Worker #10 on 10/26/23 at 9:07 A.M. verified Resident #74's last
documented care conference was dated 09/20/22 and should be done quarterly.
Residents Affected - Some
4) Review of the medical record for Resident #59 revealed an admission date of 11/02/21. Diagnoses
included acute and chronic respiratory failure with hypercapnia, chronic kidney disease, heart failure,
COPD, and major depressive disorder. Further review of the medical record revealed no documented
evidence that a care conference had been completed for the last 12 months.
Review of the quarterly MDS assessment dated [DATE] for Resident #59 revealed the resident had intact
cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15.
Interview with SSD #51 on 10/26/23 at 9:17 A.M. verified Resident #59 had not had a care conference
completed in the last 12 months.
Review of policy titled, Policy and Procedure for Resident Rights, Advanced Directives, and Advanced Care
Planning last revised 09/01/22, revealed the facility will routinely review with the resident and his/her
representative to ensure that existing care instructions were in line with the resident's wishes and establish
to continue or change these instructions. This was completed at a minimum quarterly and with significant
change in status.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365712
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365712
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookwood Retirement Community
12100 Reed Hartman Highway
Cincinnati, OH 45241
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, staff interview, and policy review, the facility failed to ensure resident's meal trays
were delivered in a hygienic manner. This affected four residents (#61, #06, #77 and #79) out of 24
residents observed for dining service. The facility census was 108.
Findings include:
Observation the third floor during lunch tray meal delivery on 10/23/23 revealed the following: At 12:36 P.M.,
State Tested Nursing Assistant (STNA) #152 was observed pulling multiple food trays from the food carts
and delivering them to residents in the Skyline lounge with gloved hands. STNA #152 was observed to
deliver and set up resident's trays without changing her gloves and/or completing any hand hygiene. STNA
#152 assisted Resident #61 with positioning in her wheelchair and moved the resident closer to table.
STNA #152 continued to pull food trays and deliver them to the residents in the Skyline Lounge without
changing her gloves and/or performing any hand hygiene. At 12:39 P.M., STNA #152 pulled the meal tray
for Resident #06 and delivered it to the resident's room. STNA #152 placed the meal tray on the resident's
bedside table and exited the room with the same pair of gloves on. At 12:47 P.M., STNA #152 pulled the
meal tray for Resident #77 and delivered it to the resident's room. STNA #152 set up the meal tray for the
resident by removing the cover to all items with the same pair of gloves on. At 12:58 P.M., STNA #152
pulled the meal tray for Resident #79 and delivered it to the resident's room. STNA #152 set up the meal
tray for the resident by removing the cover to all items and placed condiments on the resident's food with
the same pair of gloves on.
Interview with STNA #152 on 10/23/23 1:04 P.M. verified she did not change her gloves and /or complete
any hand hygiene as she delivered and set the residents lunch trays. STNA #152 stated she did not know
what the process was for appropriately delivering and setting up meal trays.
Review of 03/01/23 facility policy titled General Infection Control Hand Washing / Hand Hygiene revealed
the facility will assure a safe sanitary and comfortable environment and control the development and
transmission of infections and diseases. All staff will perform hand hygiene after removing gloves or other
personal protective equipment before eating, drinking, or handling food.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365712
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365712
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookwood Retirement Community
12100 Reed Hartman Highway
Cincinnati, OH 45241
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0917
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground
level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident and staff interviews and record review, the facility failed to provide furniture suitable
for the comfort of the residents and/or the visitors. This affected one (#29) out of 24 residents reviewed. The
facility census was 108.
Findings include:
Review of the medical record for Resident #29 revealed the resident was admitted to the facility on [DATE].
Diagnosis included, but is not limited to, asthma, essential hypertension, bipolar disorder, anxiety, irritable
bowel syndrome, dysphagia, age related osteoporosis, chronic obstructive pulmonary disease (COPD), and
metabolic encephalopathy.
Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 07/28/23 for Resident #29,
revealed the resident was cognitively intact.
Observation of Resident #29's room on 10/23/23 11:54 A.M., revealed there was no chair for the resident
and/or visitors to sit on. Interview at the same time with Resident #29 revealed she was concerned with not
having a chair to sit on in her room.
Interview with the Administrator on 0/25/23 at 10:32 A.M., revealed every resident's room should have a
chair for the resident and/or a visitor to sit on. The Administrator verified Resident #29 did not have a chair
available for the resident to sit in and was unaware the resident's room did not have a chair.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365712
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F917 - Private closet space in each resident room, as specified in §483
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
FAQ · About this visit
Common questions about this visit
What happened during the October 26, 2023 survey of BROOKWOOD RETIREMENT COMMUNITY?
This was a inspection survey of BROOKWOOD RETIREMENT COMMUNITY on October 26, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BROOKWOOD RETIREMENT COMMUNITY on October 26, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.