Brookdale Carriage Club Providence

Based on observation and staff interviews, the facility failed to perform hand hygiene between handling soiled and then clean dishes to prevent cross-contamination of the clean dishes. These practices had the potential to affect food served and distributed to 9 of 9 residents who received an oral diet. Findings included: A continuous observation of the skilled nursing satellite kitchen was conducted on 04/02/25 from 1:09 PM through 1:16 PM. Dietary Aide #1 was observed operating the dish machine and washing dishes. Dietary Aide #1 had gloves on both hands with left hand glove observed with large ripped in area over the palm. While waiting for the dish cycle to complete, she removed food debris from soiled plates in the sink area located to the right of the dish machine in the dish room and then moved to the drying area side of the dish machine wearing the same gloves. Dietary Aide #1 then opened the dish machine after the washing cycle was completed. She removed all the clean dishes which consisted of 8 bowls, 2 plates, 1 soup bowl, 4 ice cream scoops, 5 pieces of silverware, and 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to treat 1 of 3 sampled residents with dignity by performing care in a manner that the resident felt was rude and hurried (Resident #117). The findings included: Resident #117 admitted to the facility on [DATE] with diagnoses which included a compression fracture of the second lumbar vertebra. A review of Resident #117's comprehensive care plan dated [DATE] revealed a focus area for alteration in musculoskeletal status related to the compression fracture of the second lumbar vertebra. The interventions included that she required the mechanical lift for transfers. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #117 was cognitively intact. An initial allegation report dated [DATE] revealed an allegation of abuse. The allegation indicated on [DATE] Resident #117 called the Administrator to her room to express concerns about NA #1 when she was providing her care the evening of [DATE]. Resident #117 told the Administrator that NA #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and nurse practitioner interviews, the facility failed to maintain accurate advance directive information throughout the electronic and paper medical records for 1 of 3 residents reviewed for advance directive (Resident #119). The findings included: Resident #119 was admitted to the facility on [DATE]. A review of the nursing admission note dated [DATE] at 2:42 PM indicated that Resident #119 was alert and verbal. A review of Resident #119's electronic medical record revealed an order written by the nurse practitioner dated [DATE] for full code status. This order was created by the Director of Clinical Services. A review of Resident #119's comprehensive care plan revealed a focus area for advance directives initiated on [DATE] indicating Resident #119's code status was a full code. The goal was for Resident #119's wishes and directives to be carried out in accordance with her advanced directives through the next review date. An intervention was to honor resident choice for code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to label and date leftover food items stored for use, discard dented canned goods stored for use, maintain a utility cart in clean condition that was used to transport clean dishware, keep a food storage area clean and orderly, failed to ensure a scoop was stored without the potential for cross-contamination, failed to dry metal prep pans and plastic plate covers prior to stacking, failed to ensure metal plate warmers were clean prior to use, and failed to maintain a hand washing sink in good repair. These practices occurred in the walk-in refrigerator, walk-in freezer, dry goods storage area, and had the potential to affect food served to residents. The findings included: 1. An initial tour of the main kitchen occurred on 2/19/24 at 9:45am with the Dietary Manager (DM). The main kitchen served all buildings on campus. The following concerns were identified: a. Items in the walk-in refrigerator that were not sealed included: -cut pineapple in a metal serving pan not completely covered with plastic wrap with a prep date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and to monitor interventions that the committee had previously put in place following the recertification survey on 09/14/2022. This was for a deficiency in the area of food safety requirements (F812). The continued failure since the previous survey of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: This tag was cross referenced to: F812: Based on observations and staff interviews, the facility failed to label and date leftover food items stored for use, discard dented canned goods stored for use, maintain a utility cart in clean condition that was used to transport clean dishware, keep a food storage area clean and orderly, ensure a scoop was stored without the potential for cross-contamination, dry metal prep pans and plastic plate covers prior to stacking, failed to ensure metal plate warmers were clean prior to use, and maintain a hand washing sink in good…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record reviews the facility failed to honor food choices for 3 of 3 sampled residents (Residents #8, #10, #4) reviewed for preferences. The deficient practice had the potential to affect 9 residents who received food from the kitchen. The findings included: a. Resident #8 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #8 was cognitively intact. The MDS also indicated Resident #8 needed partial or moderate assistance when eating. A review of Resident #8's care plan dated 1/29/24 revealed Resident #8 was at increased nutrition/hydration risk related to variable food intakes related to frequent nausea and was at risk for weight loss and malnutrition. The goal identified no significant weight change. Interventions included monitoring meal intake with each meal, offering supplements as ordered, and monitoring weights as ordered. An interview with Resident #8 on 2/19/24 at 11:37 a.m. indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, residents and staff interviews, the facility failed to maintain lighting, cabinets, and walls in good repair for 1 of 1 hall (resident rooms 214, 222) and 1 of 1 activity room nutrition area reviewed for clean, comfortable and homelike environment. The findings included: a. An observation on 2/19/24 at 11:18am revealed a brown, dried splatter on the wall across from the resident bed in room [ROOM NUMBER]. A second observation was conducted on 2/21/24 at 9:30am with the Administrator, Maintenance Director #1, and the Housekeeping Supervisor. The observation revealed a brown, dried splatter on the wall across from the resident bed. An interview with the Housekeeping Supervisor on 2/21/24 at 9:46am revealed that housekeeping staff were responsible for cleaning rooms, bathrooms, dispensers, toilets, sinks, sweeping and mopping, wiping down televisions, beds, remotes, and bedside tables. The bathroom vent covers were to be cleaned during a deep cleaning session, not on a regular basis. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and Physician and staff interview the facility failed to provide a treatment as ordered by the physician to a non-pressure wound for 1 of 1 resident (Resident # 214) reviewed for wound care. The findings included: Resident # 214 was admitted to the facility on [DATE]. The Care Plan dated 02/01/2024, revealed Resident # 214 had a potential/actual impairment to skin integrity. The Care Plan documented goal for Resident # 214 was to be free from skin breakdown. Resident # 214 interventions included, to evaluate skin condition on a daily and weekly basis, keep skin clean and dry, use lotion on dry skin and not apply to area of skin breakdown, wound, or between toes. The Minimum Data Set (MDS) dated [DATE], revealed Resident #214's cognition was moderately impaired and she had no behaviors. The MDS documented Resident #214 had no refusal of care and she had no documentation of her skin tear noted. The physician's order dated February 2024, revealed Resident # 214 was to receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews the facility failed to remove loose garbage, food, and debris from around 1 of 1 trash receptacle located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests/rodents. The findings included: An observation of the outdoor trash receptacle area on 2/19/24 at 2:20pm revealed a clear bag of trash on the ground outside of the receptacle and boxes of used COVID tests on the ground underneath the bag. The ground around the enclosure was littered with food scraps to include an apple, vegetable peeling, and labels from boxes and a dark brown sludge. During the observation the receptacle door was noted to be open and there was a broken dining tray cart on the left side of the dumpster and a discarded beverage serving cart on the ground outside of the receptacle enclosure. An interview with Dietary Manager (DM) on 02/21/24 at 10:46am revealed the kitchen staff was responsible for the outdoor trash area. An interview with the Administrator on 2/21/24 11:43am indicated she was not aware there was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.