Brookdale Morehead City

The facility failed to ensure that one of five sampled residents had a completed FL-2 medical examination updated annually. Specifically, Resident #5 had not had an updated FL-2 completed since September 9, 2023.

The facility failed to ensure that resident care plans were accurately signed by the assessor upon completion. This was evidenced by a review of Resident #5's record where the care plan lacked the required assessor signature.

The facility failed to ensure that one of five sampled residents had a required annual medical examination (FL-2) completed. Specifically, Resident #5 had not received an updated medical examination since September 2023. Staff interviews indicated that the Health and Wellness Director failed to complete the update due to staffing shortages and lack of time.

The facility failed to ensure the Resident Register was completed and signed within 72 hours of admission for 4 out of 5 sampled residents. Specifically, for Resident #1, the Resident Register lacked an admission date despite the resident having been admitted on 06/21/24.

The facility failed to ensure the Resident Register initial assessment was completed and signed by the administrator or designee and the resident or representative within 72 hours of admission. Specifically, for 4 of 5 sampled residents, the Resident Register lacked admission dates and required signatures from the administrator and the responsible person.

The facility failed to maintain matching therapeutic diet menus for all physician-ordered diets to guide food service staff. Specifically, for 3 of 6 sampled residents, there were no posted gluten-free, low sodium, carbohydrate-controlled, or low fat/low cholesterol menus to correspond with the daily regular menus.

The facility failed to administer medications as ordered for 2 of 6 sampled residents. Specifically, errors were identified regarding medications used for pain, thinning mucus, thinning blood, a vitamin supplement, and a laxative. For one resident, documentation showed inconsistent administration of Aspirin EC and Acetaminophen, with several doses missed or recorded with incorrect dosages.

The facility failed to administer medications as ordered for one resident, including errors involving medications for pain, mucus, blood thinning, vitamins, and laxatives. Specifically, for one resident, there was no documentation regarding missed doses of Aspirin EC 81mg despite inconsistent charting entries.

The facility failed to administer medications as ordered for one resident, including errors involving medications for pain, mucus, blood thinning, vitamins, and laxatives. Specifically, records showed that Aspirin EC 81mg was not consistently administered or documented correctly according to the physician's orders.