Brookdale South Park

The facility failed to provide adequate supervision for a resident with dementia and agitation, resulting in an elopement from the Special Care Unit. The resident exited the secured area through a kitchen door without staff knowledge and was found outside near a main road. Additionally, an unalarmed service entry/exit door was observed that did not always close completely.

The facility failed to ensure that a resident's physician signed and dated the care plan within 15 calendar days of the completion of the assessment. Specifically, for one resident, the care plan was not signed by the physician until 27 days after the assessment was completed.

The facility failed to ensure that 4 of 5 sampled residents had an accurate care plan signed by a physician within 15 days of the assessment. For example, Resident #4's care plan was not signed by the physician until 27 days after the assessment was completed.

The facility failed to ensure that 5 of 5 sampled residents had a Special Care Unit (SCU) resident profile completed within 30 days of admission and updated on a quarterly basis. The profiles lacked required assessment data regarding behavioral patterns, physical abilities, and cognitive impairment.

The facility failed to ensure the documentation of treatment orders for one resident regarding the use of compression stockings. While orders existed for the application and removal of TED hose, the facility failed to document the implementation of these orders and failed to provide the necessary supplies, resulting in the resident not wearing the stockings during observations.

The facility failed to ensure proper documentation and implementation of physician orders for one resident regarding compression stockings. Specifically, the facility could not provide consistent documentation of the application and removal of compression stockings as ordered, and observations showed the resident was not wearing the stockings during inspection hours.

The facility failed to implement and maintain CDC, NC DHHS, and local health department recommendations regarding COVID-19 protection. Specifically, the facility did not take rapid action to re-test residents and staff who previously tested negative following a July 2020 outbreak, nor did they properly screen staff upon entry.

The facility failed to implement physician orders for Resident #4 regarding blood sugar parameters. Specifically, the facility did not follow protocols for notifying the physician, rechecking fingerstick blood sugar, and administering sliding scale insulin coverage when blood sugar levels were elevated.