Brookdale Wake Forest

The facility failed to ensure that two of seven sampled medication aides had completed the required state-approved medication training and clinical skills validation. Specifically, documentation was missing for staff members regarding their training completion and skills validation.

The facility failed to ensure that one of five sampled residents received a two-step tuberculosis (TB) test upon admission. Records for Resident #5 did not show evidence of the required TB testing as mandated by state regulations.

The facility failed to ensure that medication aides completed required state-approved training and clinical skills validation. Specifically, personnel records for three staff members (E, F, and G) lacked documentation for required medication training or clinical skills validation.

The facility failed to ensure medications were administered within one hour before or one hour after the prescribed or scheduled time. This was evidenced by 4 out of 5 sampled residents receiving medications for seizures, blood thinning, pain, and mental health outside of the required window.

The facility failed to ensure proper referral and follow-up to meet the healthcare needs of residents. Specifically, for Resident #1, the facility failed to document notification to the endocrinologist despite multiple instances of elevated blood sugar levels that met the criteria for physician notification.

The facility failed to ensure proper referral and follow-up to meet the healthcare needs of residents. Specifically, the facility failed to provide adequate follow-up for one resident following an unwitnessed fall with a head injury and failed to manage elevated blood sugar levels and delayed insulin administration for another resident.

The facility failed to ensure that 2 of 6 sampled staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR). Specifically, documentation of an HCPR check was missing for one staff member, and no personnel record or HCPR documentation was available for review for another staff member.

The facility failed to assure that 1 of 6 sampled staff members had a criminal background check completed in accordance with state regulations. There was no personnel record available in the business office for review for this staff member.

The facility failed to maintain clean and orderly kitchen, dining, and food storage areas. Observations revealed food debris, paper, and liquid spills on kitchen and dining floors, as well as dirty equipment, including the stove, burners, and walk-in cooler/freezer surfaces.