Brookdale Union

The facility failed to maintain hot water temperatures at a maximum of 116°F for four resident bathroom fixtures. Specifically, water temperatures were measured as high as 121°F in rooms 31, 37, 39, and 41. A resident reported having to adjust the water because it became too hot during showers.

The facility failed to administer medications as ordered by a licensed prescribing practitioner for one resident. Specifically, seven doses of Klonopin were missed between June 9, 2021, and June 11, 2021, due to the medication being unavailable from the pharmacy.

The facility failed to administer medications as ordered by a licensed prescribing practitioner for one resident. Specifically, the resident missed seven doses of Klonopin between June 9, 2021, and June 11, 2021, because the medication was unavailable from the pharmacy and staff failed to ensure the prescription was refilled in time.

The facility failed to ensure that ceilings and floor coverings were kept clean and in good repair. Multiple locations throughout the facility were observed with stained, worn, or discolored carpeting and water-stained ceilings.

The facility failed to ensure that medications were administered according to the orders of a licensed prescribing practitioner. Specifically, for one resident, medication orders for Carbidopa-Levodopa were not correctly transcribed or administered in accordance with updated dosage and frequency instructions.

The facility failed to provide adequate supervision for two residents with a history of falls. Specifically, records for Resident #2 showed multiple unwitnessed falls, including an incident where the resident hit her head and required emergency room treatment, indicating a failure to follow care plans and supervision needs.

The facility failed to ensure therapeutic diets were served as ordered for two residents requiring texture-modified diets. Specifically, a resident with dysphagia was served food without required gravies, a potato with the peel intact, and pecan pie containing nuts. Additionally, staff were unaware of the specific dietary restrictions for texture-modified diets and had previously served unsafe desserts containing nuts.