Brookdale Pinehurst

The facility failed to ensure that all residents receive a completed assessment within 30 days of admission and annually thereafter. Based on interviews and record reviews, the facility failed to meet requirements for one of three sampled residents regarding the assessment process.

The facility failed to ensure that Resident #3 had a completed assessment within 30 days of admission. While the resident was admitted on 06/09/25, a review of the records revealed that no care plan was available for review.

The facility failed to ensure that medications were administered as ordered for one of three residents observed during a medication pass. Specifically, errors were noted regarding medications intended to treat depression and slow the progression of Alzheimer's disease.

The facility failed to ensure medications were administered as ordered for one resident. During an 8:00am medication pass, the medication aide failed to include citalopram in the resident's morning medications, resulting in an 8% medication error rate.

The facility failed to ensure physician orders were implemented for a resident who required weekly weights. Specifically, an order for weekly weights was entered incorrectly into the electronic medication administration record (eMAR), resulting in a lack of documentation for weights in March, April, and May 2022.

The facility failed to ensure physician orders were implemented for a resident who required weekly weights. Specifically, an order for weekly weights was entered incorrectly into the electronic medication administration record (eMAR), resulting in a lack of documentation for weights in March, April, and May 2022.

The facility failed to administer medications as ordered for two residents during medication passes. This included a medication aide failing to administer a prescribed dose of Propranolol to a resident despite checking their blood pressure and documenting the results.

The facility failed to ensure the safe storage of oxygen tanks on the Assisted Living Unit and failed to maintain a hazard-free environment for 11 residents on the Special Care Unit. Specifically, the facility did not follow safety protocols regarding the secure storage and handling of compressed gas cylinders.

The facility failed to ensure that one out of five sampled staff members had a tuberculosis (TB) test completed upon hire. There was no documentation of a TB skin test, chest x-ray, or baseline symptom screening in the employee's personnel record.

The facility failed to implement physician-ordered treatments and procedures for two out of six sampled residents. Specifically, the facility did not document oxygen saturation levels as ordered for Resident #5 and failed to implement orders for twice-weekly weights to monitor fluid overload for Resident #6.