Brookdale Macarthur Park

The facility failed to ensure a resident received their prescribed texture-modified therapeutic diet. During breakfast service, a personal care aide mistakenly served the resident a standard plate intended for another resident, which could have posed a choking risk.

The facility failed to ensure that the preparation and administration of medications and treatments are in accordance with orders by a licensed prescribing practitioner and facility policies.

The facility failed to ensure a resident with a texture-modified diet order received the correct meal. During breakfast service, a personal care aide served the resident another resident's plate, and the dining services manager failed to include the correct therapeutic diet plate on the food cart because he incorrectly believed the resident was hospitalized.

The facility failed to provide personal care for a resident who waited between 13 and 56 minutes for staff assistance after using the pendant call system. Specifically, the resident required assistance with dressing, grooming, showering, and transfers due to high fall risk and incontinence, but staff response times were significantly delayed.

The facility failed to provide timely personal care for a resident who required assistance with dressing, grooming, and transfers. Specifically, the resident waited between 13 and 56 minutes for staff response to pendant call alerts, resulting in at least one instance of the resident urinating on themselves.