Providence Place

Inspectors wroteThe facility identified a census of 35 residents. The facility had one main kitchen and one dining area. The facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals. The facility also failed to ensure food items were labeled and dated when opened. These deficient practices placed residents at risk for contamination and foodborne illness.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of eight cognitively impaired, independently mobile residents. The facility additionally failed to safely transfer Resident (R) 37, resulting in a non-injury fall, and ensure R9's fall interventions were followed. This placed the affected residents at risk for preventable accidents. Findings Included:- On 08/10/25 at 10:10 AM, an initial walkthrough of the facility was completed. An inspection of the 300 Hall revealed an unsecured cabinet across from the vending machine that contained disinfectant bleach wipes and a Clorox spray bottle. [...]

Inspectors wroteThe facility reported a census of 44 residents. The facility identified two medication rooms and four medication carts. Based on observations, record reviews, and interviews, the facility failed to secure one of two medication storage rooms. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included:- On 08/10/25 at 10:05 AM, an initial walkthrough of the facility was completed. An inspection of the 100 Hall Team Office medication storage room revealed that the door was not secured. An inspection of the medication storage room revealed shelves of stock medication, enteral feeding solutions, and medical supplies. On 08/10/25 at 10:11 AM, Licensed Nurse (LN) G stated the door should be locked at all times due to the medications in the room. She stated that sometimes the doorknob would stick and not close properly. [...]

Inspectors wroteThe facility identified a census of 35 residents. The facility identified seven residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to ensure trash was stored and contained properly. The facility further failed to ensure trash was not left on top of the Personal Protective Equipment (PPE) cart, and the clean linen door was not propped open. The facility further failed to ensure soap and paper towels were available in the same room, and gloves were available in the dirty laundry area, and all staff knew where the hand washing sink was in the laundry room. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility reported a census of 44 residents. The sample included 12 residents, with one reviewed for activities of daily living (ADL). Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 17 received supportive care and services to promote and maintain his quality of life when the facility failed to provide him with his required adaptive utensils while eating his meals. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. [...]

Inspectors wroteThe facility identified a census of 35 residents. The sample included 12 residents, with three residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 23 with ensuring his fingernails were kept clean. This deficient practice placed R23 at risk for impaired dignity, comfort, and further decline in ADL. Findings Included: [...]

Inspectors wroteThe facility identified a census of 35 residents. The sample included 12 residents, with two residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently communicate Resident (R) 51 medical condition with a pre- and post-dialysis communication prior to and post-hemodialysis. This deficient practice placed R51 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 12 residents, with four residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 4 had a documented risk assessment that included alternatives that had been tried and failed. This placed the R4 at risk for uninformed decisions and impaired safety related to the risks associated with the use of siderails.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to act upon the Consultant Pharmacist (CP) recommendations for Resident (R) 4. This deficient practice placed R4 at risk for unnecessary medication use, side effects, and physical complications.

Inspectors wroteThe facility reported a census of 36 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report) when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing.

Inspectors wroteThe facility had a census of 29 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents. Based on record review, interviews, and observations, the facility failed to provide wheelchair foot pedals for Residents (R)15, R178, R21, and R175. This deficient practice placed the residents at risk for impaired safety and comfort. Findings Included: - On 10/30/23 at 07:34AM staff transported R15 from the main hallway to the dining room in a wheelchair. R15's wheelchair lacked foot pedals. R15 wore socks and his feet slid on the floor as he was pushed to the dining room. A review of R15's Care Plan revealed no documented interventions related to his foot pedals. On 10/30/23 at 11:33PM housekeeping staff pushed R178 down the main hallway in his wheelchair. R178's wheelchair did not have foot pedals in place and his feet made contact with the ground on several occasions. [...]

Inspectors wroteThe facility reported a census of 29 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage of medications for one of three medication rooms. This deficient practice placed the residents at risk for unnecessary medication and administration errors and/or diversion. Findings Included: - On 10/20/23 at 07:05AM a walkthrough of the facility's Prairie View hallway revealed the medication storage room door was propped fully open and unattended by nursing staff. The medication storage cart within the room was left unlocked and contained medications for all five residents on the Prairie View hallway, Resident (R)8, R11, R13, R19 and R125. At 07:21AM Licensed Nurse (LN) G entered the hallway and reported the medication room should not have been left open. She stated she was not sure why the room was propped open, or the cart left unlocked. [...]

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R)127's medical provider of her weight loss or changes in meal intake. This deficient practice placed R127 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients) due to delayed physician involvement. Findings Included: - The Medical Diagnosis section within R127s Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), muscle weakness, history of fractures (broken bones), and history of falls. [...]

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to secure protected health information (PHI) for Resident (R)125. This deficient practice placed R125 at risk for decreased psychosocial wellbeing due to lack of privacy. Findings Included: - The Medical Diagnosis section within R125's Electronic Medical Records (EMR) included diagnoses of fracture of right femur (broken bone), aphasia (difficulty speaking), dementia (progressive mental disorder characterized by failing memory, confusion), and a cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). [...]

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents. Based on observations, record review, and interviews, the facility failed to provide the necessary care and services for activities of daily living (ADL) for Resident (R)5 when staff pulled on R5 under her arms instead of using available equipment to assist in repositioning her. This deficient practice placed R5 at risk for injury.

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 had the physician-ordered ankle foot orthotics (AFO-brace that supports the ankle and foot)and services to prevent reduction of range of motion [ROM] and/or mobility. This deficient practice left R1 at risk for further decline and decreased ROM or mobility.

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized interventions to improve/maintain Resident (R)15's bowel and bladder incontinence. This deficient practice placed R15 at risk for complications related to incontinence. Findings Included: - The Medical Diagnosis section within R15s Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, acute kidney failure, history of falls, weakness, and a need for assistance with personal care. R15's admission Minimum Data Set (MDS) dated 10/14/23 noted a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment. The MDS indicated he required partial to moderate assistance with toileting care and transferring. [...]

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents with one reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to monitor Resident (R)127's weight loss or changes in dietary intake. This deficient practice placed R127 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients). Findings Included: - The Medical Diagnosis section within R127s Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), muscle weakness, history of fractures (broken bones), and history of falls. [...]

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to provide adequate pulse monitoring for Resident (R)125's anti-hypertensive beta-blocker (class of medication used to treat high blood pressure). This deficient practice placed R125 at risk for unnecessary medications and adverse medication effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 34 residents. Based on observations, record reviews, and interviews, the facility failed to ensure appropriate hand hygiene during dining service; the facility failed store respiratory equipment in a sanitary manner; and the facility failed to maintain sanitary handling of clean linen. This placed the affected residents at increased risk for infections. Findings Include: - On 03/28/22 at 09:18 AM an observation of R20's room revealed his oxygen tubing and nasal cannula (breathing device that delivers concentrated oxygen into both nostrils) lying on top of his soiled bed pad on his bed. An inspection of R20's oxygen concentrator (machine that delivers measurable prescribed oxygen to residents) revealed that the concentrator had no bag for storing the cannula or date indicating how long the tubing has been in use. [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents, with four residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to acknowledge and honor Resident (R) 18's right for self-determination to sleep undisturbed without feeling interference, or reprisal from the facility staff. The facility further failed to ensure R24's and R25's right to be treated with respect, dignity, and care during meals. These deficient practices placed the residents at risk for negative psychosocial outcomes and decreased autonomy and dignity.

Inspectors wroteThe facility identified a census of 34 resident. The sample included 13 residents with five residents reviewed for baseline care plan. Based on observations, record reviews, and interviews, the facility failed to develop a baseline care plan which included fall interventions for Resident (R)181. This deficient practice placed her at risk for accidents and injury. Findings Included: - The electronic medical record (EMR) documented the following diagnosis for R181: dementia (progressive mental disorder characterized by failing memory, confusion), repeated falls, and difficulty walking. The Entry Tracking Minimum Data Set ( MDS) recorded R181 admitted to the facility on [DATE]. R181's admission MDS was in progress on date of review on 03/30/22. An admission Fall Assessment completed on 03/22/22 indicated R181 was a fall risk related to poor balance and gait. [...]

Inspectors wrote- The electronic medical record for R2 documented diagnoses of end stage renal disease (ESRD-medical condition in which the kidneys cease functioning on a permanent basis) and dependent on renal dialysis dated 06/08/21. The Significant Change Minimum Data Set (MDS) dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. He required limited to extensive assist of one staff for his activities of daily living (ADLs). He required the use of a mechanical lift for transfers and a wheelchair for mobility. Dialysis was not indicated for R2 while not a resident nor while a resident. The Quarterly MDS dated 03/15/22 documented R2 had a BIMS score of 15 which indicated intact cognition. He required limited to extensive assist of one staff for ADLs. He used a wheelchair for mobility that he self-propelled. [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents with five reviewed for bathing. Based on observations, record reviews, and interviews, the facility failed to provide consistent bathing per the residents' preferences and bathing schedules for Residents (R) 18, and R25. This deficient practice placed the resident at risk for poor hygiene and impaired psychosocial well-being.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents, with seven residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure staff utilized the care planned interventions for Resident (R) 18 to prevent falls and failed to implement appropriate interventions aimed at preventing falls for R25, who was identified as a high fall risk. The facility failed to implement preventative fall measures upon admission as well as appropriate fall interventions immediately after a fall for R181, who was at risk for falls. These deficient practices placed residents at risk for injury related to falls.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents. One resident, Resident (R) 129, was sampled for ileostomy (a surgical formation of an opening through which fecal matter emptied) care. Based on observation, record review and interview, the facility failed to ensure a physician's order for ileostomy care (when to change, how often to change, how often to check the ostomy) and appropriate application of the necessary cares. This deficient practice left R129 at risk for complications related to the ileostomy such as infection and skin breakdown.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents. Four residents were sampled for respiratory care. Based on observation, record review, and interview, the facility failed to ensure that staff provided the necessary respiratory care and services when staff failed to properly change, dated and stored oxygen (O2) tubing when not in use for resident (R)130 and R20, which left these resident at risk for unwarranted respiratory complications.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 13 residents. One resident was sampled for dialysis (the process of removing excess water and wastes from the blood in people whose kidneys no longer function on their own) care. Based on observation, record review and interview, the facility failed to ensure that Resident (R)2 had a physician's order for dialysis and failed to ensure critical information such as the name and location of the dialysis center, a contact number, the time of treatment and transportation to/from the dialysis clinic was documented on R2's clincial record. This deficient practice left R2 at risk for improper care and treatment.