Brookdale Robinwood

The facility failed to ensure proper referral and follow-up for a resident's healthcare needs. Specifically, staff failed to notify the Primary Care Physician when the resident's systolic blood pressure was 110 or less or when their pulse was less than 60, as required by physician orders. Documentation showed multiple instances where blood pressure and pulse readings fell outside of ordered parameters without evidence of physician notification.

The facility failed to ensure that exit doors had a continuous sounding device activated upon opening. This resulted in a disoriented, exit-seeking resident leaving the facility without staff being alerted, leading to the resident being found by EMS alongside a road.

The facility failed to ensure that exit doors opening to the outside had a continuously sounding device activated upon opening. This was evidenced by Resident #1, who was disoriented and exit-seeking, being able to exit the facility without alerting staff.

The facility failed to properly monitor and document the orientation levels of residents. Specifically, for Resident #1, there was no documentation of their orientation status despite a diagnosis that included anxiety and cerebral vessel malformation.

The facility failed to ensure that all new physician orders, discharges, and FL-2 forms were consistently reviewed and processed. There was a lack of documented verification that new orders were being entered into tracking forms and forwarded for coordination of care.

The facility failed to provide adequate supervision for a resident, resulting in the resident sustaining 10 unwitnessed falls within a two-month period. Despite the resident's diagnoses of disorientation and semi-ambulatory status, the facility did not implement supervision consistent with the resident's assessed needs and care plan.

The facility failed to implement adequate monitoring and documentation protocols following incidents or accidents. Specifically, there was a lack of frequent checks and documented supervision for 72 hours following an event, as well as a lack of daily audits for incident reports and resident records.

The facility failed to ensure physician notification for a resident with uncontrolled diabetes mellitus following elevated finger stick blood sugar readings. Specifically, there was no documentation that the endocrinologist was notified when blood sugar levels exceeded the prescribed threshold of 300 for three consecutive checks in November and December 2018.

The facility failed to maintain walls, ceilings, and floors in good repair, as evidenced by significant carpet staining and debris in seven resident bedrooms. Observations revealed various dark, brown, and reddish stains, as well as food and paper debris, across multiple rooms. Resident interviews indicated that carpet stains from spills are persistent and that the carpeting requires replacement.

The facility failed to ensure that floor coverings were kept clean and in good repair. Observations in seven resident bedrooms revealed various carpet stains, food debris, and paper debris. Interviews with residents indicated that stains from spills are frequent and that existing cleaning methods are ineffective.

The facility failed to ensure that all staff and live-in non-residents are tested for tuberculosis disease upon employment or living in the home. The regulation requires testing in compliance with established control measures for all applicable personnel.