Brookdale High Point

The facility failed to provide table service with non-disposable place settings for residents receiving meals in their rooms. Observations and interviews confirmed that meals were being served using disposable Styrofoam trays, bowls, cups, and plastic utensils. Residents reported that their meals are consistently served on disposable plates and with plastic cutlery.

The facility failed to provide table service with non-disposable place settings, including knives, forks, spoons, plates, and beverage containers, for residents eating in their rooms. Observations and interviews revealed that meals were being served using disposable Styrofoam trays, bowls, cups, and plastic utensils. The Dietary Manager noted that this practice had been occurring for six months due to a shortage of non-disposable items and a lack of staff to wash dishes.

The facility failed to administer medications as ordered for a resident. Specifically, while the physician's order required diltiazem 180mg daily, the facility was found to have 240mg tablets on hand instead of the correct dosage. This discrepancy occurred because the mail-order pharmacy had processed an incorrect dosage based on a lack of proper prescription documentation.

The facility failed to administer medications as ordered for one resident. Specifically, there were errors identified in the administration of diltiazem, a medication used to regulate heart rate, as evidenced by discrepancies in the electronic medication administration record.

The facility failed to provide adequate supervision for two residents related to high fall risks, including one resident who experienced eight falls in four months. Specifically, the facility did not follow its own policy to ensure supervision was provided in accordance with assessed needs and care plans to prevent further incidents.

The facility failed to provide adequate supervision for two residents in accordance with their assessed needs and care plans. Specifically, the facility failed to implement necessary interventions for a resident who experienced eight falls within four months and another resident who had two falls, one resulting in injury.

The facility failed to ensure physician notification and follow-up for a resident following a rescheduled neurology appointment. This resulted in the abrupt discontinuation of anti-psychotic and anti-anxiety medications, specifically gabapentin, without a physician's order to stop the medication.

The facility failed to administer medications as ordered by a licensed prescribing practitioner for two sampled residents. Specifically, Resident #5 missed a dose of Cymbalta, and Resident #1 missed three consecutive doses of Coumadin between June 22 and June 24, 2017. The facility lacked a system for tracking Coumadin or INR levels to ensure compliance with physician orders.