Brookdale Country Day Road

The facility failed to provide adequate supervision for a resident with a history of repeated falls. This resulted in an unwitnessed fall where the resident remained on the floor for an unknown period of time during the overnight hours.

The facility failed to provide adequate supervision for a resident with a history of repeated falls. This resulted in an unwitnessed fall where the resident was found lying on the floor for an unknown period of time during the overnight hours.

The facility failed to ensure that 3 out of 6 sampled staff members had documentation of a North Carolina Health Care Personnel Registry (HCPR) check completed prior to their hire dates. Specifically, personnel records for Staff D, E, and F lacked evidence of required HCPR verification at the time of employment.

The facility failed to ensure that all staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR) prior to hire. Specifically, a review of 6 sampled staff members found that 3 individuals (Staff D, E, and F) lacked documentation of an HCPR check completed before their employment began.

The facility failed to ensure clear and complete medication orders for Resident #5 regarding insulin administration. The Health and Wellness Coordinator noted 'per sliding scale' on the FL-2 instead of writing out the specific instructions, and there was no audit process to ensure these orders were correctly entered into the eMAR.

The facility failed to clarify medication orders for 3 of 7 sampled residents, including a steroid medication for Resident #2 and a steroid enema for Resident #4. Specifically, the facility did not verify if two different doses of Prednisone should be administered simultaneously, creating a risk of receiving an excessively high dose.

The facility failed to clarify unclear or incomplete medication orders with the resident's physician. Specifically, staff failed to clarify overlapping steroid doses for Resident #2 and sliding scale insulin instructions for Resident #5, which could have resulted in medication errors or incorrect dosing.

The facility failed to ensure proper referral and follow-up for a resident's acute health care needs. Specifically, staff failed to notify hospice services regarding new open areas discovered on the resident's skin on the buttocks.

The facility failed to ensure proper referral and follow-up for a resident's acute health care needs. Specifically, staff failed to notify hospice services regarding new open areas in the skin on the resident's buttocks.