Health inspection·November 27, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure residents' private care information was not posted in areas visible to the public. This affected 14 (#85, #86, #87, #88, #89, #91, #95, #97, #98, #99, #101, #103, #106, and #108) of 16 residents reviewed for privacy. The facility census was 106. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE]. Diagnoses included central cord syndrome at C6 level of the cervical spine, generalized muscle weakness, major depressive disorder, contracture right hand, unspecified anxiety disorder, and an unstageable pressure ulcer to the right heel. 2. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, unspecified anxiety disorder, type II diabetes, and repeated falls. 3. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE] and had diagnoses including type II diabetes, stage III chronic kidney disease, chronic gout, unspecified anxiety, and unspecified depression. 4. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and spondylolisthesis of the lumbosacral region. 5. Review of the medical record revealed Resident #89 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, unspecified anxiety disorder, and unspecified heart failure. 6. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] and had diagnoses including repeated falls, unspecified polyneuropathy, polyosteoarthritis, and unspecified pain. 7. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE] and had diagnoses including type II diabetes, morbid obesity, repeated falls, major depressive disorder, and unspecified chronic pain. 8. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE] and Page 1 of 3 365712 365712 11/27/2024 Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241

F 0583 Level of Harm - Minimal harm or potential for actual harm had diagnoses including unspecified dementia, an unstageable pressure ulcer to the sacral region, late-onset Alzheimer's disease, major depressive disorder, generalized anxiety disorder, and repeated falls. 9. Review of the medical record revealed Resident #98 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease, type II diabetes, and unspecified anxiety disorders. Residents Affected - Some 10. Review of the medical record revealed Resident #99 was admitted to the facility on [DATE] and had diagnoses including hypertension, unspecified depression, and history of falling. 11. Review of the medical record revealed Resident #101 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, type II diabetes, major depression disorder, stage III pressure ulcer to left heel, and heart failure. 12. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE] and had diagnoses including unspecified heart failure, type II diabetes, unspecified dementia, and chronic kidney disease. 13. Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] and had diagnoses including hemiplegia affecting left non-dominant side, unspecified chronic pain, and unspecified seizures. 14. Review of the medical record revealed Resident #108 was admitted to the facility on [DATE] and had diagnoses including spina bifida, repeated falls, and generalized muscle weakness with need for assistance with personal care. Observation on 11/27/24 at 8:35 A.M. revealed, midway down the hallway on the left hand side of the hall, a mounted computer monitor in a kiosk with a bedside table and chair in front. Further observation revealed papers were observed to be taped to the wall surrounding the kiosk and identified Resident #85, Resident #86, Resident #87, Resident #89, Resident #91, Resident #99, and Resident #106 were morning get-ups and Resident #86, Resident #95, Resident #97, Resident #98, Resident #99, and Resident #106 were lay-downs. Each resident's name and room number were identified on the papers. There was an additional list posted with the title, Dining Room List Lunch and Dinner, which included eight (#88, #89, #97, #98, #99, #103, #106, and #108) resident names and room numbers. Observation of the bedside table in the hall revealed shower sheets were visible on top of bedside table with names handwritten at the top of the page for Resident #88 and Resident #101. During an interview on 11/27/24 at 8:44 A.M. Certified Nurse Aide (CNA) #226 stated the papers were always displayed on the wall like that so the nurse aides would know what care was due for those residents. During an interview on 11/27/24 at 8:50 A.M. Licensed Practical Nurse (LPN) #242 stated the area in the hallway was the nurse aides' work station. LPN #242 verified the documents posted and viewable in the public area on the hall displayed resident names, room numbers, and clinical and personal information regarding care activities and dining location for 14 (#85, #86, #87, #88, #89, #91, #95, #97, #98, #99, #101, #103, #106, and #108) residents. This deficiency represents an incidental finding discovered during the complaint investigation. 365712 Page 2 of 3 365712 11/27/2024 Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, medical record review and policy review, the facility failed to ensure residents received adequate nail care. This affected one (#15) of three residents reviewed for activities of daily living (ADLs). The facility census was 106. Residents Affected - Few Findings include: Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, unspecified vascular dementia, unspecified contracture, unspecified epilepsy, and type II diabetes. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #15 required substantial/maximal assistance with personal hygiene, bathing, upper body dressing, and toileting. Review of the care plan dated 10/20/20 revealed Resident #15 had an ADL self-care performance deficit. Interventions included staff assistance with ADLs, mechanical (Hoyer) lift for all transfers, promoting dignity by ensuring privacy, right hand/forearm splint daily as tolerated up to 10 hours, and showers twice weekly on Wednesdays and Saturdays. Review of shower sheets dated 11/06/24, 11/09/24, 11/12/24, 11/16/24, 11/20/24, and 11/23/24 revealed Resident #15 received bed baths. There was no documentation which indicated whether fingernail care was offered and provided or refused. Observation on 11/27/24 at 9:00 A.M. revealed Resident #15's left hand, third fingernail appeared broken and jagged. Resident #15's left fourth and fifth fingernails were overgrown from the base of the finger pad by approximately one-third of an inch. During an interview on 11/27/24 at 9:00 A.M. Resident #15 stated staff trimmed his fingernails every once in a while, but not with every shower or bath. The resident did not recall the last time his fingernails were trimmed. During an interview on 11/27/24 at 10:31 A.M. Licensed Practical Nurse (LPN) #250 verified Resident #15's fingernails on the left hand were sharp and needed to be trimmed down. LPN #250 verified the fingernails appeared trimmed close to the finger pads on right hand. During an interview on 11/27/24 at 3:07 P.M. Corporate Registered Nurse (RN) #55 verified the facility had no documented evidence that fingernail care was offered or provided to Resident #15. Review of policy titled, ADL Care, dated 11/2023, revealed a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00158680. 365712 Page 3 of 3