Brookdale Smithfield

The facility failed to ensure that 3 of 6 medication administration staff had completed the required medication clinical skills checklist evaluation. Specifically, for one staff member, there was no documentation of a passed medication aide test, employment verification, or completed clinical skills competency validation.

The facility failed to ensure that 3 of 6 medication staff members had a completed medication clinical skills checklist evaluation prior to administering medications. Specifically, for Staff B, there was no documented hire date, no documentation of passing the medication aide test, and no documentation of a completed clinical skills validation checklist.

The facility failed to ensure proper referral and follow-up care for a resident following a fall. Specifically, the facility did not ensure the resident attended a scheduled orthopedic follow-up appointment or notify the primary care provider regarding blood pressure and weight loss fluctuations outside of ordered parameters.

The facility failed to ensure proper referral and follow-up for a resident who required an orthopedic follow-up appointment after a knee fracture. Additionally, the facility failed to notify the primary care provider regarding blood pressure readings and weight loss that were outside of ordered parameters.

The facility failed to ensure that one of two sampled staff members completed a required two-step tuberculosis (TB) skin test. Specifically, personnel records for a medication aide showed a second step of the TB skin test was not documented following the initial test performed in September 2019.

The facility failed to ensure sufficient staff and supplies were available to maintain kitchen cleanliness and sanitary conditions on an ongoing basis.

The facility failed to ensure that one of eight sampled staff members had a completed North Carolina Health Care Personnel Registry (HCPR) check upon hire. Documentation showed the check was not performed at the time of hire on 10/08/19, though subsequent checks were performed later.

The facility failed to properly track and verify new medication orders. There was a lack of consistent review of electronic Medication Administration Records (eMARS) against current physician orders and a need for better implementation of order tracking forms.

The facility failed to maintain an adequate cleaning schedule and oversight for the kitchen area. There was a lack of consistent verification that equipment was in working order and that staff were following proper cleaning procedures.

The facility failed to properly audit records for residents self-administering medications and ensure that appropriate assessments and physician orders were in place for those wishing to self-administer.

The facility failed to ensure that milk was consistently offered or served at two meals per day, including breakfast, for residents in Assisted Living and Memory Care, unless medical contraindications were documented.

The facility failed to maintain proper oversight for residents requiring Licensed Health Professional Support (LHPS) tasks. The plan of correction indicates a need for improved auditing of resident records and quarterly reviews for those with LHPS tasks.

The facility failed to ensure that one of six sampled staff members had successfully completed the required 80-hour personal care training and competency evaluation program. Personnel records for the staff member showed a hire date of 6/09/16 with no documentation of completed training.

The facility failed to ensure that one of six sampled staff members had successfully completed the required 80-hour personal care training and competency evaluation program. Personnel records for the staff member showed a hire date of 6/09/16 with no documentation of completed training. This lack of training was noted during an observation where a resident was left in the day room wearing only underwear and a shirt.