Brookdale Forest City

The facility failed to maintain an accurate therapeutic diet list for food service staff guidance. Specifically, 2 of 4 sampled residents were not correctly documented on the kitchen's therapeutic diet list, including one resident requiring a carbohydrate controlled diet and another requiring a texture modified regular diet.

The facility failed to maintain an accurate therapeutic diet list for food service staff. Specifically, two out of four sampled residents were missing from the posted list, including one resident requiring a carbohydrate controlled diet and another requiring a texture modified regular diet with ground meat and no gravy.

The facility failed to ensure proper referral and follow-up to meet the acute health care needs of a resident. Specifically, the facility did not notify the prescriber regarding incorrect and missed doses of a blood thinner and failed to ensure that required laboratory tests were completed as ordered.

The facility failed to ensure proper referral and follow-up for a resident's acute health care needs. Specifically, the facility did not notify the prescriber regarding incorrect and missed doses of a blood thinner and failed to ensure ordered laboratory tests were completed.

The facility failed to ensure the primary care provider was notified regarding a resident's refusal of ordered bloodwork and a failure to schedule a required eye appointment. Specifically, for one resident, there was no documentation that the physician was informed of multiple blood draw refusals or the lack of a glaucoma monitoring appointment.

The facility failed to ensure the primary care provider was notified regarding a resident's refusal of bloodwork and a failure to schedule a required eye appointment. There was no documentation that the physician was informed of these missed medical orders or the resident's refusal of care.

The facility failed to properly document and implement physician orders, specifically regarding the tracking of bloodwork and specialist appointments. Records showed orders for bloodwork and eye appointments were not completed or documented as implemented in the resident's record.

The facility failed to ensure that one of five sampled Medication Aides had received required training on the care of diabetic residents prior to administering insulin. Personnel records showed no documentation of training for the staff member, who had been administering insulin injections since late September 2019.

The facility failed to ensure that food stored in the produce cooler and freezer was protected from contamination. Specifically, observations revealed unlabeled and undated food, as well as food boxes sitting directly on the floor of the freezer.

The facility failed to ensure that a Medication Aide received required training on the care of diabetic residents prior to administering insulin. Personnel records showed no documentation of training for the staff member, despite records indicating they had administered insulin injections to a resident between 11/04/19 and 11/12/19.