Brookdale Elizabeth City

The facility failed to ensure food items were protected from contamination by failing to properly label, date, and secure food products. Specific observations included expired food items, unlabeled opened mixes, and unsecured bags of flour in the kitchen pantry.

The facility failed to ensure that a Licensed Health Professional Support (LHPS) review and evaluation was completed for 2 of 5 sampled residents. Specifically, one resident required an evaluation for the administration of a suppository medication, and another resident required an evaluation due to an order for continuous oxygen use.

The facility failed to ensure that a Licensed Health Professional Support review and evaluation was completed within the required timeframe for 2 of 5 sampled residents. Specifically, evaluations were missing for a resident with an order for a rectal suppository and a resident with an order for oxygen.

The facility failed to provide adequate supervision and post-fall evaluations according to resident care plans and facility policy. Specifically, one resident experienced 14 falls within a five-month period, resulting in skin tears, abrasions, a head injury, and two emergency room visits.

The facility failed to provide adequate supervision and post-fall evaluations in accordance with resident care plans and facility policy. Specifically, one resident with a high fall risk experienced 14 falls over a five-month period, resulting in skin tears, abras, a head injury, and two emergency room visits.

The facility failed to ensure proper health care referral and follow-up for a resident. Specifically, they failed to schedule a dental appointment for the resident's tooth pain and failed to schedule a follow-up appointment with the primary care physician within two days of the resident's discharge from the emergency department.

The facility failed to ensure medication was administered within the required timeframe. Medication administration must occur within one hour before to one hour after the scheduled time, and any delays must be documented in the electronic record.

The facility failed to properly document medication administration, specifically regarding controlled substances. This includes failures in documenting the administration of medications as ordered, the effectiveness of as-needed medications, and the accuracy of narcotic counts during shift changes.

The facility failed to ensure proper health care referral and follow-up for a resident experiencing tooth pain and following an emergency department discharge. Specifically, the facility did not schedule a timely dental appointment for the resident's toothache and failed to schedule a follow-up appointment with the resident's primary care physician regarding a wound.

The facility failed to ensure the front exit door was equipped with a sounding device that activates when opened. This lack of monitoring allowed residents with dementia and disorientation to exit the facility without staff knowledge, including one resident who was later found deceased.