Brookdale Asheville Overlook

The facility failed to administer medications as ordered for 3 of 6 sampled residents, specifically involving missed blood pressure medications, incorrect dosages, and missed insulin. In one instance, a medication aide applied only a patch cover instead of the prescribed clonidine patch, resulting in a resident experiencing a hypertensive emergency and ICU admission.

The facility failed to administer medications as ordered for 3 of 6 sampled residents, including a failure to apply a prescribed clonidine patch for Resident #1. This error resulted in the resident experiencing a hypertensive emergency and admission to the ICU. The investigation revealed the medication aide applied only the patch cover instead of the medicated patch due to rushing.

The facility failed to ensure the county department of social services was notified of accidents requiring referral for emergency medical evaluation. Specifically, there were no incident or accident reports or evidence of DSS notification for Resident #2's falls that resulted in emergency department evaluations on 07/04/22 and 09/28/22.

The facility failed to notify the county department of social services regarding an accident that required a referral for emergency medical evaluation. Specifically, for one sampled resident, an emergency department visit following a fall and head injury was not reported as required.

The facility failed to ensure that one of five sampled staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR) before being hired. A review of the employee's personnel record showed no documentation of an HCPR check was performed prior to their hire date.

The facility failed to ensure that one of five sampled staff members had a North Carolina Health Care Personnel Registry (HCPR) check completed prior to hire. Personnel records for the employee lacked documentation of the required background check. Interviews with management indicated a lack of awareness regarding the requirement to complete these checks before employment.

The facility failed to ensure that housekeeping tasks performed by aides on the second shift before 9:00 p.m. were limited to occasional, non-routine tasks. Evidence showed aides were routinely responsible for laundry, cleaning dining room tables, and emptying trash, which exceeded the allowed scope of duties given the staffing levels.

The facility failed to limit personal care staff food service duties to only assisting residents with eating and carrying items. Based on interviews and record reviews, staff were performing broader food service duties beyond the permitted scope.

The facility failed to ensure that housekeeping tasks performed by aides on the second shift before 9:00 p.m. were limited to occasional, non-routine tasks. Staffing reviews and interviews revealed that personal care aides were routinely performing laundry duties and cleaning dining room items, which exceeded the permitted scope of duties for that shift.