Brookdale Charlotte East

The facility failed to implement physician orders for blood pressure checks for Resident #4. Specifically, an order from 05/03/24 requiring daily blood pressure monitoring for seven days was not entered into the eMAR system or followed, leaving the resident at risk for unmonitored hypotension.

The facility failed to implement and document physician orders for daily blood pressure checks for one resident. Specifically, a physician's order from May 2024 for seven days of morning blood pressure monitoring was not entered into the eMAR system or performed.

The facility failed to ensure follow-up for a resident's acute health care needs, resulting in the resident not receiving prescribed levothyroxine sodium for hypothyroidism for approximately three months. Medication administration records showed numerous undocumented doses of the medication throughout July, August, and September 2022.

The facility failed to maintain the environment without chronic unpleasant odors of urine. Observations in resident room #1222 revealed strong urine odors, urinals containing dark urine left near beds and wheelchairs, overflowing trash, and soiled laundry. Additionally, urine spills were noted on the floor and bed, and a dark stain was observed under a resident's recliner.

The facility failed to maintain the resident environment without chronic unpleasant odors of urine. Observations in room #1222 revealed strong urine odors, full urinals left on the floor and tables, overflowing trash, and soiled laundry. Additionally, urine stains were noted on the flooring under a resident's recliner.

The facility failed to ensure physician notification regarding a resident's increased risk of depression and increased pain levels. Specifically, while the resident's physician was notified of medication refusal, the facility failed to adequately address the clinical implications of the resident's emotional distress and physical pain documented in the resident log.

The facility failed to provide adequate supervision for two residents related to falls. Specifically, one resident experienced multiple falls resulting in significant injuries including fractures and a head injury, while another resident on isolation protocol experienced a wrist fracture and subdural hematoma. There was no documentation of interventions to reduce falls, and staff were unaware of necessary increased supervision or updated care plans.

The facility failed to provide adequate supervision for two residents related to falls, resulting in serious injuries including fractures and a subdural hematoma. Specifically, the facility did not implement increased supervision or update care plans to manage a resident's high frequency of falls and documented need for assistance with ambulation.