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
(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 3
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
11/27/2024
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365712
If continuation sheet
Page 2 of 3
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
11/27/2024
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365712
If continuation sheet
Page 3 of 3