Providence Living Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide adequate supervision for Resident (R) 1, who took medications to prevent alcohol relapses and was at risk for self-harm, to prevent an elopement and the staff did not identify the resident was missing for over nine hours. On 06/14/2026 at approximately 04:18 AM staff observed R1 wandering in the facility and this was the last time staff knew R1's whereabouts. On 06/14/2026 at approximately 02:00 PM, staff identified R1 was not in her room, and it appeared she had not been there all day. During the time R1 was out of the facility, without staff knowledge or supervision, there were severe thunderstorm warnings, flash flood warnings, and the temperatures ranged from a low of 55 degrees Fahrenheit (F) to highs of 81 degrees F. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Inspectors wroteBased on record review and interview, the facility failed to identify an elopement that went undiscovered by staff for over eight hours as an allegation of neglect and report it to the State Agency (SA) as required. (Refer to F689)

Inspectors wroteThe facility identified a census of 69 residents. The sample included three residents. Based on record review, observation, and interview, the facility failed to ensure medications were secured and inaccessible to residents. On 02/11/26 at 07:55 PM, the pharmacy delivered three bags of medications to the facility, which included one white bag, one blue bag, and one red bag. The red bag contained 90 tablets (tabs) of alprazolam (a medication used to treat anxiety, panic disorders, and depression) and 90 tabs of lorazepam (a medication used to treat anxiety, insomnia, and seizure disorders). Licensed Nurse (LN) G took possession of the medications and left them in the nurse's station without securing them. At 09:55 PM, Resident (R) 1 and R2 identified the nurse's station was unmanned. [...]

Inspectors wroteThe facility identified a census of 67 residents. The sample included 17 residents. Based on interview and record review, the facility failed to ensure adequate staffing levels on the weekends to meet the needs of the residents.

Inspectors wroteThe facility had a census of 67 residents. Based on observation, interview, and record review the facility failed to provide the services of a full-time certified dietary manager for the residents who resided in the facility and received their meals from the kitchen.

Inspectors wroteThe facility reported a census of 67 residents, and one kitchen. Based on interviews, observations, and record review, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food-borne bacteria.

Inspectors wroteThe facility reported a census of 67 residents; the sample included 17 residents. Based on record review and interview, the facility failed to ensure the Medical Director ( or designee) attended Quality Assurance Performance Improvement (QAPI) meetings at least quarterly.

Inspectors wroteThe facility had a census of 67 residents. Based on record review and interview, the facility failed to ensure the staff member designated as the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control and possessed the required certification.

Inspectors wroteThe facility census totaled 67 residents. Based on observation, interviews and record review, the facility failed to maintain the building in good condition and provide a safe and hazard free environment for the residents, visitors and staff.

Inspectors wroteThe facility reported a census of 67 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, sanitary and homelike environment in the facility.

Inspectors wroteThe facility had a census of 67 residents. The sample included 17 residents with four residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 1, R33 R52 and R70. Additionally, the facility failed to notify the Ombudsman for transfers.

Inspectors wroteThe facility reported a census of 67 residents; the sample included 17 residents sampled with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to acknowledge the Consultant Pharmacist's monthly medication regimen review (MRR) and failed to ensure the MRR recommendations were filed in the clinical record for Resident (R) 1, R7, R9, R13, and R30.

Inspectors wroteThe facility identified a census of 67 residents. The sample included 17 residents with five residents reviewed for vaccinations. Based on record review nad interview, the facility failed to ensure the residents were offered and received the pneumococcal vaccine or informed declinations for the vaccine were obtained for Resident (R) 13, R5, R6 and R34.

Inspectors wroteThe facility reported a census of 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to provide a safely secured handrail in the stairwell corridor leading to the basement.

Inspectors wroteThe facility reported a census of 67 residents, the sample included 17 residents. Based on interview and record review, the facility failed to inform Resident (R) 1 and R13 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility identified a census of 67 residents. The sample included 17 residents with one resident reviewed for advanced directives. Based on observation, record review, and interviews, the facility failed to accurately identify Resident (R) 30's advanced directives for a Do Not Resuscitate (DNR- expressed desire to not receive cardiopulmonary resuscitative measures in the event of cardiac or respiratory arrest).

Inspectors wroteThe facility reported a census of 67 residents. The sample included 17 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with nail care for Resident (R) 9, who participated in her hygiene activities but needed staff assistance.

Inspectors wroteThe facility reported a census of 67 residents; the sample included 17 with one resident reviewed for prevent decrease in range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) and mobility. Based on observation, interview, and record review, the facility failed to provide a palm guard to prevent contractures (abnormal fixation of a joint or muscle) to Resident (R) 44.

Inspectors wroteThe facility had a census of 67 residents. The sample included 17 residents, with one resident reviewed for smoking. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 33 when staff failed to assess R33 for safe smoking ability and determine if safety equipment was required.

Inspectors wroteThe facility had a census of 67 residents. The sample included 17 residents, with one resident reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to apply, clean, and store a continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) within the standards of practice for Resident (R) 3.

Inspectors wroteThe facility reported a census of 67 residents; the sample included 17 residents with one resident reviewed for trauma. Based on observation, interview, and record review the facility failed to implement approaches for trauma informed care to prevent triggers that were identified for Resident (R) 33, who had a history of personal trauma.

Inspectors wroteThe facility reported a census of 67 residents. The sample included 17 residents with two residents reviewed for bed rail safety. Based on interview, observation, and record review, the facility failed to assess Resident (R)1 and R29 for safe use and necessity of the bed rails. The facility further failed to obtain and document that risks of bed rail use were explained and informed consent from the resident and/or representative was obtained.

Inspectors wroteThe facility reported a census of 67 residents. The sample included 17 residents with two residents reviewed for bed rail safety. Based on interview, observation, and record review, the facility failed to inspect the bed rails to ensure correct and secure installation on the beds for Resident (R)1 and R29.

Inspectors wroteThe facility reported a census of 67 residents. Based on observations, interviews, and record review, the facility failed to maintain and / or dispose of kitchen garbage and refuse properly.

Inspectors wroteThe facility identified a census of 72 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure staff monitored and reported lab results to the provider as they became available in order to treat Resident (R) 1's urinary tract infection (UTI). This placed the resident at risk of ongoing pain with urination, agitation, and confusion related to delayed treatment of a UTI.

Inspectors wroteThe facility identified a census of 72. The sample included three residents. Based on observation, record review, and interviews, the facility failed to follow physician-ordered parameters regarding medication monitoring for Resident (R) 1. This placed the resident at risk for medication-related complications and adverse effects.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents with four reviewed for nutrition. Based on observation, record review, and interview, the facility failed to implement Registered Dietician (RD) interventions for Resident (R) 27's significant weight loss, resulting in a 12.61 % loss over three months. This also placed the resident at risk for continued weight loss. Findings Included: [...]

Inspectors wroteThe facility had a census of 76 residents. Based on observation, interview, and record review the facility failed to provide the services of a full-time certified dietary manager for the residents who resided in the facility and received their meals from the kitchen, placing the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 71 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hour data for all direct care personnel as required. This placed the residents at risk for impaired care due to unidentified staffing issues.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with effective person-centered interventions for two residents. Resident (R) 65 to include interventions related to bolus feeding by gastrostomy tube (G-tube: a tube for introducing high-calorie fluids into the stomach and R72 who had posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) with no person-centered interventions to address the PTSD. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to assess gastric (stomach) contents before administering bolus feeding by gastrostomy tube (G-tube: a tube for introducing high-calorie fluids into the stomach) for Resident (R) 65. This deficient practice placed R65 at risk for aspiration (inhaling liquid or food into the lungs) and inadequate nutrition.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 72 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization related to a diagnosis of post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the resident at risk for unmet mental health care needs.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents with one reviewed for Hospice services (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life). Based on observation, interview, and record review the facility failed to ensure Resident (R)52 received hospice services as agreed in the hospice plan of care. This placed R52 at risk for inappropriate end-of-life care.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 72 residents who resided in the facility and received their food from the facility kitchen, when the facility failed to ensure clean and sanitary food prep areas, and failed to sanitize a thermometer prior to checking temperatures of different food items. This placed the 72 residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's consultant pharmacist failed to notify the Director of Nursing (DON), medical director, or physician of recommendations for a 14 day stop date or physician's rationale for extended use on as needed (PRN) psychotropic medications (medications used to treat mental illness, moods, behaviors) for two sampled residents, Resident (R) 1, R42, and a 14 day stop date for a PRN antipsychotic medication (class of medications used to treat psychosis and other significant mental conditions) for R45. This placed the residents at risk for unnecessary psychotropic medications and adverse side effects.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a 14 day stop date or physician's rationale for extended use for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for two sampled residents, Residents (R) 1, and R42, and a 14 day stop date for a PRN antipsychotic medication (class of medications used to treat psychosis and other significant mental conditions) for R45. This placed the residents at risk for unnecessary psychotropic medications and adverse medication side effects.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents with five reviewed for accidents/falls. Based on observation, record review, and interview, the facility failed to provide occupational therapy (OT) and physical therapy (PT) services as ordered by the physician to prevent falls for one sampled resident, Resident (R) 38. This placed the resident at risk for continued falls with injuries.