Brookdale Carriage Club Providence I

The facility failed to ensure necessary referral and follow-up to meet the acute health care needs of a resident. Specifically, the facility did not notify the pharmacy or the provider when a medication for high cholesterol and a vitamin deficiency was not delivered after being re-ordered, resulting in five missed doses of atorvastatin calcium.

The facility failed to ensure that 6 of 6 sampled residents had a care plan signed by a physician or physician extender within 15 days of the resident's assessment. This includes a failure to maintain required physician certification of diagnoses and associated limitations within the required timeframe.

The facility failed to ensure that 6 out of 6 sampled residents had a care plan signed by a physician or physician extender within 15 days of the resident's assessment. Specifically, the care plans for Resident #1, #2, and #5 were identified as lacking the required physician signatures.

The facility failed to ensure that one of four sampled residents had completed required tuberculosis (TB) testing upon admission. A review of Resident #5's records showed no TB information on the FL2 and only one recorded TB test from 2017.

The facility failed to administer medications as ordered for two of five sampled residents. Specifically, there was no documentation that Hyoscyamine Sulfate was administered to Resident #1 in October 2021, despite an active hospice order for the medication.

The facility failed to ensure one of four residents had completed required tuberculosis testing upon admission. Specifically, Resident #5's records lacked necessary TB information, and the Health and Wellness Director had not audited charts for completion since being hired.

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The facility failed to ensure physician notification for two sampled residents who had physician's orders for daily blood pressure monitoring and lab collection. Specifically, for Resident #4, there was no documentation of blood pressure checks on the eMAR from 10/19/16 through 1/12/17, despite an active order for daily monitoring with specific parameters for reporting.

The facility failed to ensure physician notification for residents with specific monitoring orders. Specifically, for Resident #4, the facility failed to perform daily blood pressure monitoring and notify the physician of results outside of the ordered parameters (systolic BP less than 90 or greater than 160) for a period spanning from October 19, 2016, through January 12, 2017.