Providence Healthcare

Inspectors wroteBased on observation, record review, staff interviews, and review of the facility policy titled Freedom of Abuse - Abuse Prevention Fast Alert and the Certified Nursing Assistant (CNA) job description, the facility failed to assess and provide wound care in a timely manner to one resident (R) (R9) reviewed for wound care. On 2/21/2026, actual harm occurred when CNA BB neglected to provide (R9) adequate incontinent care, resulting in R9 developing a blister on the left upper thigh. R9 required a debridement to remove necrotic tissue on 3/5/2026. The sample size was 9.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled Freedom Of Abuse Abuse Prevention Fast Alert the facility failed to ensure an allegations of neglect was reported to the State Survey Agency (SSA) within the required time frame for one Resident (R) (R9) of nine sampled residents. Resident (R9) verbally and via text reported to the facility that one Certified Nursing Assistant (CNA) BB neglected to provide her (R9) adequate incontinent care. As a result, R9 developed a blister on the left upper thigh. Due to the delay in care the blister progressed to an open wound.

Inspectors wroteBased on observation, record review, interviews, and review of the facility policy titled RAI Care Planning Management the facility failed to implement the care plan interventions for a newly develop pressure ulcer for one (1) Resident (R) (R9) out of nine (9) care plans reviewed.

Inspectors wroteBased on record review, staff interview, review of the facility policy titled Freedom Of Abuse Abuse Prevention Fast Alert the facility failed to ensure Georgia Criminal History Check System (GCHEXS) Fingerprint check was conducted for one (1) Certified Nursing Assistant (CNA) of ten employee files selected for review. The facility census was eighty residents. Review of the policy titled Freedom of Abuse Abuse Prevention Fast Alert dated 1/2025. revealed Pre-Employment Screening: When a potential new employee is considered for hire, take the following steps to ensure the applicant is suitable for hire. 3. Criminal Background Checks are required; all employment candidates are required to authorize the facility to conduct a background check for conviction of crimes. The Human Resource Manager's job description was requested but not provided. [...]

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility policies titled Management of Laundry and Infection Control Manual, the facility failed to ensure that laundry staff followed infection control processes while performing laundry services and failed to ensure the laundry room was maintained in a sanitary condition. In addition, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed for one of two residents with a gastrostomy tube (G-Tube) [a tube surgically inserted through the abdomen into the stomach used to deliver nutrition, fluids, and medications]. These deficient practices had the potential to place residents at risk of infections due to cross-contamination. The census was 73 residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Infection Control Manual, the facility failed to ensure three of five sampled residents (R) (R1, R29, and R13) for vaccinations had a completed consent, declination and/or proof of education for the pneumococcal and/or influenza vaccine. This deficient practice had the potential to place R1, R29, and R13 at risk of unmet needs.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Incontinence Management, the facility failed to ensure a urinary catheter privacy bag was provided for one of one resident (R) R2 with a urinary catheter. This failure had the potential to diminish the resident's quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled Medication Administration, the facility failed to remove expired medications from one of four medication carts and failed to remove expired medication and medical supplies from one of two medication rooms. The facility's census was 73.

Inspectors wroteBased on observations, resident representative (RR) interview, and staff interviews, the facility failed to provide a sanitary and comfortable environment for one of 53 sampled residents (R) (R58). This deficient practice had the potential to place R58 at risk of living in an uncomfortable environment.

Inspectors wroteBased on observations, staff interviews, and review of facility policies titled Procedure for Washing Pots and Pans, and Proper Temperatures For Meal Preparation and Service, and review of the EcoLab Product Specification document for the Multi-Quat Sanitizer, the facility failed to demonstrate the proper usage of the three-compartment sink to sanitize dishware to prevent contamination, failed to allow dishware items to air dry, and failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit (F) to prevent bacteria growth. These deficient practices had the potential to place residents consuming an oral diet at risk of contracting a foodborne illness. The facility census was 69 with 68 residents receiving an oral diet.

Inspectors wroteBased on observation, staff interview, record review, and review of facility policy titled Skin Management Standards, the facility failed to provide wound treatment per the physician's order and failed to wash/sanitize hands and change gloves during wound treatment for one resident (R) (R67) of three residents reviewed for pressure ulcers. This deficient practice had the potential to place R67 at risk for medical complications and infection.

Inspectors wroteBased on observations, interviews, and review of the facility's infection control policy titled, Pandemic Pathogen Plan (Coronavirus), and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure that all staff were wearing face masks appropriately when the COVID-19 county transmission level for the facility was high. This had the potential to affect all 67 residents in the facility.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy titled, RAI [Resident Assessment Instrument]/Care Planning Management, the facility failed to develop person-centered, comprehensive care plans for four (Resident [R] #13, R#35, R#57 and R#60) of 24 residents whose care plans were reviewed. Specifically, the facility: - Failed to develop a care plan that addressed behavioral management for R#13. - Failed to develop a care plan that addressed R#35's pressure ulcer care. - Failed to develop a care plan with resident-specific interventions addressing R#57's nutritional needs and tracheostomy care. - Failed to develop a care plan for R#60 that accurately addressed behavioral symptoms that were pertinent to the resident.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure staff followed physician orders regarding medication dosing and wound care frequency for three (Resident [R] #35, #51, and #65) of four sampled residents reviewed for physician orders.

Inspectors wroteBased on interviews, record review, the facility failed to promote and facilitate resident self-determination for one (Resident [R] #51) of four sampled residents reviewed for pain management. Specifically, the facility failed to ensure nursing staff honored R#51's choice regarding acceptance or refusal of specific medications.

Inspectors wroteBased on record review, interviews, and facility policy titled Change of Condition/Incident Reporting, the facility failed to notify the responsible party (RP) of a resident's change of condition. The RP was not notified of a hospital transfer or notified when the resident returned from the hospital with a diagnosis of COVID-19. This affected one [Resident (R) #19] of one resident reviewed for notification of changes of condition.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure prompt efforts were made to resolve residents' grievances and the results of those efforts were communicated to the resident for two (Resident [R] #51 and R#55) of five sampled residents reviewed for grievances related to missing personal property. Specifically, the facility: - Failed to ensure R#51's verbal complaint of missing clothing was documented as a grievance, efforts were promptly made to locate the clothing, and the resident was kept informed of efforts to resolve the grievance. - Failed to ensure R#55's grievance related to missing money was thoroughly investigated.

Inspectors wroteBased on interviews, record review, facility policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to ensure staff immediately reported an allegation of staff-to-resident abuse to the Administrator for one (Resident [R] #13) of one sampled resident reviewed for abuse. The facility further failed to ensure the allegation of staff-to-resident abuse was reported to the State Survey Agency (SSA) for R#13.

Inspectors wroteBased on interviews, record review, facility policy review, and review of an incident report and police report, it was determined the facility failed to investigate an allegation of staff-to-resident physical abuse for one (Resident [R] #13) of one sampled resident reviewed for abuse.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to change an indwelling urinary catheter at the frequency specified by the physician for one (Resident [R] #62) of three sampled residents reviewed for urinary catheters.