Providence Care Center

Inspectors wroteBased on medical record review, staff interviews, hospital record review, and review of facility policy, the facility failed to accurately and timely assess an acute change in condition (lack of assessments), failed to collaborate with the surgeon and failed to timely recognize significant changes in condition for a post-surgical resident resulting in delayed interventions. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcomes on 06/04/26 at 12:02 P.M. when Resident #100 was seen by Vascular Surgeon #250 and the left lower extremity was assessed to have palpable femoral pulses bilaterally with no appreciable flow detected in the distal left lower extremity with no distal pulses palpable, absent sensation over the left foot with preserved sensation at a more proximal level, and clammy skin with mottled discoloration. [...]

Inspectors wroteBased on medical record review, staff interviews, hospital record review and review of facility policy, the facility failed to ensure Eliquis (an oral anticoagulant medication used to prevent and treat blood clots) was administered as ordered by the physician. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcomes on 06/04/26 at 12:02 P.M. when Resident #100 was seen by Vascular Surgeon #250 and the left lower extremity was assessed to have palpable femoral pulses bilaterally with no appreciable flow detected in the distal left lower extremity with no distal pulses palpable, absent sensation over the left foot with preserved sensation at a more proximal level, and clammy skin with mottled discoloration. [...]

Inspectors wroteBased on observation, medical record review, resident interview, staff review, and review of facility policy, the facility failed to ensure therapy ordered positioning equipment was utilized. This affected one (#39) of three residents reviewed for positioning and position equipment. The facility census was 97.

Inspectors wroteBased on observation, staff interviews, resident interviews, and policy review revealed the facility failed to ensure required respiratory treatments were implemented as ordered. This affected one (#39) of two residents identified for requiring continuous positive airway pressure (CPAP) devices. The facility census was 97.

Inspectors wroteBased on review of the medical record, staff interview, review of a Self-Reported Incident (SRI) investigation, review of staff schedules and timekeeping records, and policy review, the facility failed to complete a thorough investigation into a resident's allegation of verbal and physical abuse. This affected one (Resident #53) of three residents reviewed for abuse. The facility census was 93.

Inspectors wroteBased on staff interview and medical record review, the facility failed to ensure the resident's medical record was accurate when documenting incontinence care being provided to the residents. This affected three (#33, #52, and #90) of three residents reviewed for medical record accuracy. The facility census was 93.

Inspectors wroteBased on medical record review, staff interview, resident interview, and facility policy, the facility failed to complete wound treatments and failed to complete wound treatments as prescribed by the provider. This affected one resident (#84) of three for wound care completion. The facility census was 98.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to wear appropriate Personal Protective Equipment (PPE) while providing wound care. This affected one resident (#84) observed for wound care. The facility census was 98.

Inspectors wroteBased on review of the medical record, staff interview, review of a Self-Reported Incident (SRI) investigation, review of staff schedules and timekeeping records, and policy review, the facility failed to prevent further potential abuse during the investigation of an allegation of sexual abuse when the alleged perpetrator was allowed to continue to work on the same unit while an investigation was in progress. This had the potential to affect 36 residents (#75, #27, #88, #15, #11, #95, #63, #9, #82, #16, #47, #64, #53, #42, #39, #61, #74, #23, #46, #85, #24, #68, #69, #89, #87, #41, #20, #19, #10, #66, #58, #8, #31, #67, #96, #36) residing the Cedarview unit. The facility census was 97. Review of the medical record for Resident #69 revealed an admission date of 06/07/21. [...]

Inspectors wroteBased on review of the medical record, staff interview, policy review, and review of a Self-Reported Incident (SRI) investigation, the facility failed to notify the physician of a resident change in condition. This affected one (#69) of three residents reviewed for change in condition. The facility census was 97. Review of the medical record for Resident #69 revealed an admission date of 06/07/21. Diagnoses included dementia with behavioral disturbance, osteoarthritis, depression, anxiety, visual hallucinations, and bilateral hearing loss. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #69 had severe cognitive impairment. Review of the SRI submitted on 07/08/25 at 8:41 A.M. revealed on 07/04/25 at 6:00 A.M., Resident #68 indicated Resident #69 stated Licensed Practical Nurse (LPN) #202 had touched her chest while trying to wake her up to give her medications. [...]

Inspectors wroteBased on review of the medical record, review of a Self-Reported Incident (SRI) investigation, staff interview, and review of facility policy, the facility failed to timely report an allegation of sexual abuse. This affected one (#69) of three residents reviewed for abuse and one of one SRIs submitted since the annual comprehensive survey. The facility census was 97. Review of the medical record for Resident #69 revealed an admission date of 06/07/21. Diagnoses included dementia with behavioral disturbance, osteoarthritis, depression, anxiety, visual hallucinations, and bilateral hearing loss. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #69 had severe cognitive impairment. Review of the medical record for Resident #68 revealed an admission date of 02/23/21. [...]

Inspectors wroteBased on observation, staff interview and maintenance record review, the facility failed to ensure ice machines were maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 96.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the dumpster area in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 96.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to maintain complete documentation of care provided for residents. This affected four (#14, #95, #301, and #35) of four residents reviewed for activities of daily living (ADLs). The facility census was 96.

Inspectors wroteBased on review of the facility infection tracking records, staff interview and review of the facility policy, the facility failed to ensure residents met infection criteria prior to the initiation of antibiotics. This affected 27 (#10, #11, #12, #18, #19, #24, #25, #26, #27, #30, #37, #40, #48, #50, #56, #62, #63, #64, #66, #69, #71, #75, #82, #88, #89, #102, and #301) of 27 residents reviewed for antibiotic stewardship. The facility census was 96.

Inspectors wroteBased on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified when a medication was unavailable for administration. This affected one (#57) of three residents reviewed for physician notification. The facility census was 96.

Inspectors wroteBased on observation, staff interview, resident interview, and review of the facility policy the facility failed to ensure bedding was maintained in a clean and sanitary manner. This affected one (#16) resident reviewed for soiled bedding. The facility census was 96.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure valid indications for the use of mobility restricting devices. This affected two (#3 and #56) of two residents reviewed for elopement. The facility census was 96. 1. Review of Resident #3's medical record revealed an admission date of 06/01/22. Diagnoses included Alzheimer's disease, dementia, hypothyroidism and congestive heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/25, revealed Resident #3 was severely cognitively impaired, required supervision for completing activities of daily living (ADLs) and exhibited no wandering behaviors. Further review of the MDS assessments since Resident #3's admission to the facility revealed the resident was never identified as having any wandering behaviors. [...]

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents who received psychotropic medications were monitored for behaviors, adverse effects, and efficacy. This affected one (#15) of five residents reviewed for unnecessary medications. The facility census was 96.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete timely Minimum Data Set (MDS) assessments following a significant change. This affected one (#91) of one resident reviewed for hospice services. The facility identified five residents receiving hospice services.

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure residents care plans were an accurate representation of current resident conditions This affected two (#3 and #56) of two residents reviewed for elopement. The facility census was 96.

Inspectors wroteBased on observation, resident interview, medical record review, staff interview and review of the facility policy, the facility failed to ensure residents were provided assistance with oral hygiene. This affected one (#89) of one resident reviewed for oral hygiene. The facility census was 96.

Inspectors wrote2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, psychotic disorder, and schizophrenia. Review of the five-day Minimum Data Set (MDS) assessment, dated 04/21/25, revealed Resident #15 was cognitively intact. Review of the plan of care, dated 08/28/18, revealed Resident #15 was at risk for constipation related to decreased mobility and medication side effects. Interventions included following the facility bowel protocol for bowel management and recording bowel movement pattern. Review of Resident #15's active physician orders for May 2025 revealed an order dated 04/17/25 for Oxycodone (opioid medication) five milligram (mg) oral capsule, give one capsule by mouth every six hours as needed for pain. [...]

Inspectors wroteBased on medical record review, review of optometry (vision) notes, and staff interview, the facility failed to ensure residents received routine eye care timely. This affected one (#35) of one resident reviewed for vision care. The facility census was 96.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents identified to smoke were assessed for safety. This affected one (#68) of one resident resident identified by the facility as a smoker. The facility census was 96.

Inspectors wrote2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, chronic kidney disease, panic disorder, seizures, schizophrenia, anxiety, migraine, low back pain, pain in the right leg, and pain in the right hip. Review of the MDS assessment, dated 03/31/25, revealed Resident #30 was cognitively intact. Review of the active physician orders for May 2025 revealed an order dated 05/14/25 for Vancomycin (antibiotic medication) intravenous (IV) solution 1250 milligrams/250 milliliters (mg/ml), use 1250 ml IV one time per day for cellulitis for 10 days. The scheduled time for the medication to be administered was 9:00 A.M. Observation on 05/20/25 at 12:12 P.M. revealed Resident #30 was sitting up on the side of their bed. The resident was receiving Vancomycin IV via a midline catheter at the time of observation. [...]

Inspectors wroteBased on medical record review, staff interview, family interview, and policy review, the facility failed to inform the resident and/or family regarding need to discontinue a seizure medication. This affected one (#107) of three residents reviewed for notification. The facility census was 106.

Inspectors wroteBased on observation, staff interview, review of medical record, and review of policy, the facility failed to ensure infection control policies and procedures were followed for maintaining urinary catheter bags. This affected two (#50 and #87) of three residents reviewed for urinary incontinence. The facility census was 106.

Inspectors wroteBased on observation, resident interview, staff interview, record review, review of the policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when performing high-risk resident care activities for residents on Enhanced Barrier Precautions (EBP). In addition, the facility failed to implement EBP per physician order for Resident #87. This affected four (#37, #77, #87, and #95) of 25 residents identified on EBP.

Inspectors wroteBased on observation, medical record review, resident and staff interviews, the facility failed to honor a resident's request to have a positioning side rail on her bed, to promote the resident's ability to assist with bed mobility. This affected one (#87) of 23 sampled residents for accommodation of needs. The facility census was 96.

Inspectors wroteBased on record review and staff interview, the facility failed to submit a new Pre-admission Screening and Resident Review (PASARR) when a resident received a new diagnosis of bipolar disorder. This affected one (#71) of two residents reviewed for PASARR. The facility census was 96.

Inspectors wroteBased on observations, medical record review, policy review, resident and staff interviews, the facility failed to ensure a daily dressing was completed for a diabetic ulcer. This affected one (#95) of two residents reviewed for skin ulcers. The facility census 96.

Inspectors wroteBased on observations, medical record review, policy review, resident and staff interviews, the facility failed to ensure a daily dressing was completed for a pressure ulcer. This affected one (#95) of four residents reviewed for pressure ulcers. The facility census 96.

Inspectors wroteBased on observation, staff interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of policy, the facility failed to ensure a suprapubic catheter was positioned to allow urine to freely flow. This affected one (#77) of three residents reviewed for catheters. The facility census was 96.

Inspectors wroteBased on medical record review, resident and staff interviews, the facility failed to ensure residents received medications as ordered. This affected three (#31, #48, and #87) of 21 residents on the Cederview hallway. The facility census was 96.

Inspectors wroteBased on observations, staff interview, and review of the facility policy, the facility failed to wear hairnets in the kitchen, serve residents lunch in a sanitary manner and use proper hand hygiene when preparing foods. This had the potential to affect 109 of 109 residents who receive meals from the facility kitchen. Resident #62, identified by facility, had an order for nothing by mouth. The facility census was 110.

Inspectors wroteBased on observation, staff interview and review of the facility policy review, the facility failed to ensure medications were stored in a safe and effective manner. This had the potential to affect 31 (#14, #37, #40, #41, #43, #44, #50, #67, #68, #69, #72, #73, #74, #88, #91, #94, #99, #100, #101, #104, #109, #262, #362, #363, #364, #365, #366, #367, #368, #400 and #401) residents who receive medications in a total facility census of 110.

Inspectors wroteBased on record review, observations, staff interview and review of the facility policy, the facility failed to follow their policy and procedure for donning and doffing personal protective equipment (PPE). This affected 30 (#14, #37, #40, #41, #43, #44, #67, #68, #69, #72, #73, #74, #88, #91, #94, #99, #100, #101, #104, #109, #262, #362, #363, #364, #365, #366, #367, #368, #400 and #401) of 30 residents who reside on the Rosewood Lane hallway. In addition, the facility failed to properly disinfect a glucometer. This affected four (#67, #100, #262 and #365) residents who utilize the glucometer machine on the Rosewood Lane hallway. The facility census was 110.

Inspectors wroteBased on observations, staff interview, record review and review of the facility policy, the facility failed to apply Thrombo-Embolus Deterrent (TED) hose/compression stockings as ordered by the physician for a resident with edema. This affected one (#56) of one resident reviewed for edema. The facility census was 110.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to provide treatments for a Stage IV pressure ulcer as ordered by the physician for one resident. This affected one (#62) of three residents reviewed for pressure ulcers. The facility census was 110.

Inspectors wroteBased on observation, staff interview, record review and review of the facility policy, the facility failed to apply a Prafo boot as care planned for one resident to prevent a decline of the contracture. This affected one (#56) of three residents reviewed for positioning and mobility. The facility census was 110.

Inspectors wroteBased on record review, staff interview, review of hospital discharge documents, review of the fall investigation and review of the facility policy, the facility failed to provide adequate supervision of two assist to prevent a fall. This affected one (#56) of five residents reviewed for falls. The facility census was 110.