Providence Place

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure fingernails were trimmed and fingernail hygiene was maintained for 3 of 3 (R1,R3,R4) dependent residents reviewed for personal care.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, monitor, and revise individualized interventions to address alcohol-related behaviors for 2 of 2 residents (R1 and R2) reviewed for behavioral health services.

Inspectors wroteBased on observation, interview and document review, the facility failed to take appropriate steps to ensure raw meat items were stored and discarded in a timely manner to reduce the risk of cross contamination and potential food born illness in 1 of 1 walk- in refrigerators used in the main production kitchen. In addition, the facility failed to ensure frozen food items were stored in a clean area and in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers in the main production kitchen. This had the potential to affect all residents who consumed food from the kitchen. Furthermore, the facility failed to ensure the unit refrigerator on 1 of 6 units was kept clean to reduce the risk of cross contamination and potential food born illness.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident mail was delivered to residents on Saturdays for 4 of 4 residents (R65, R82, R51, R128) who voiced concerns with mail delivery during Resident Council. This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview, and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to the administration of as-needed (PRN) narcotic/opioid and non-narcotic medication to help facilitate person-centered care planning and reduce the risk of complication (i.e., constipation, sedation) for 4 of 4 residents (R2, R15, R23, R155) reviewed for pain. In addition, the facility failed to ensure a scheduled antifungal medication was, as applicable, evaluated for the appropriateness of its continued use and stopped per the provider order for 1 of 5 residents (R118) reviewed for unnecessary medications.

Inspectors wroteBased interview and record review, the facility failed to ensure accurate and complete clinical records for 3 of 5 residents reviewed for immunizations (R7, R59, and R130) by incorrectly documenting COVID-19 vaccinations as influenza vaccinations in the electronic medical record (EMR). This had the potential to result in inaccurate medical records, confusion regarding residents' immunization status, inappropriate clinical decision-making, and the transmission of inaccurate health information during transfers, hospitalizations, or discharge to another provider.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the need for enhanced barrier precautions (EBP) was identified and implemented for 4 of 4 residents reviewed for transmission-based precautions, three of whom (R2, R10, R135) received dialysis via dialysis access sites located on the right upper chest (a central venous catheter (CVC)), and one (R60) who had an open wound. The facility further failed to implement infection prevention and control practices related to oxygen equipment storage, handling, and use for 1 of 1 resident (R51) reviewed for oxygen therapy by failing to ensure oxygen tubing and nasal cannula equipment remained off the floor and failed to prevent potentially contaminated oxygen equipment from being reapplied to the resident without cleaning or replacement.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident's dignity was maintained for 2 of 2 residents (R60,R51) observed during personal cares. In addition, the facility failed to ensure dignity was maintained for 2 of 2 residents (R47, R134) who experienced uncontrolled loss of bladder and bowel function waiting for staff to answer their call lights.

Inspectors wroteBased on observation, interview, and document review, the facility failed to honor 1 of 1 residents (R61) request for larger than the regular/standard portion sizes, reviewed for food choices who had complained of hunger between meals when receiving the facility's standard portion size of protein.

Inspectors wroteBased on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 2 residents (R6) reviewed, whose Medicare Part A coverage ended and remained in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan was accurate and updated to reflect the resident's current transfer, mobility, ambulation, and toileting needs. The care plan contained conflicting and inconsistent interventions and functional status information, which had the potential to result in staff confusion and inconsistent care delivery for 1 of 1 resident (R128) reviewed for care planning. In addition, the facility failed to ensure two care conferences were done to correspond with the Minimum Data Set (MDS) cycle for 1 of 1 resident (R11) reviewed for care conferences.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed for 1 of 1 residents (R155) reviewed for activities of daily (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure insulin was administered as ordered for 1 of 2 residents (R2) reviewed for insulin administration and wound care was provided as ordered for 1 of 1 resident (R60) reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure orders included resident-specific settings for the use and management of non-invasive ventilation machines for 2 of 2 residents (R15, R23) reviewed for the use of CPAP/BiPAP machines. In addition, the facility failed to ensure oxygen-related orders were reinstated after hospitalizations and readmission to the facility for 1 of 1 resident (R51) who used oxygen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary behavioral health services, trauma-informed care planning, and coordinated mental health support for 1 of 1 resident (R130) reviewed for behavioral health services. The facility failed to implement interventions to address ongoing sanitation and environmental concerns in the resident's room, failed to develop and implement interventions to address R130's identified trauma triggers and feelings related to loss of control over her surroundings, and failed to revise or implement new behavioral health interventions after 10/24/25 despite continued concerns which had the potential to result in unmet psychosocial needs and unsafe living conditions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medically related social services were provided for 1 of 1 residents (R61) observed who wore mismatched shoes which caused discomfort, despite staff knowledge of the lack of matching shoes.

Inspectors wroteBased on interview and document review, the facility failed to ensure consultant pharmacist (CP) recommendations were acted upon timely for 1 of 5 residents (R129) reviewed for unnecessary medications. In addition, the facility failed to develop and/or implement a procedure outlining follow-up time frame expectations in the drug regimen review process for 1 of 5 residents (R118) reviewed for unnecessary medications.

Inspectors wroteBased on observation, and interview, the facility failed to ensure food was served at palatable temperatures for 1 of 1 residents (R88) who were observed and served cold food.

Inspectors wroteBased on interview and document review the facility failed to identify the indication for the administration of opioid medications and failed to ensure non-pharmacological interventions were attempted/offered and documented prior to the administration of as needed (PRN) opioid medications for 2 of 3 residents (R1, R2) reviewed for pain.

Inspectors wroteBased on interview and record review the facility failed to include in the care plan interventions for safe eating and swallowing for 1 of 2 residents (R1) reviewed for quality of care and treatment.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop and implement an individualized behavioral health care plan utilizing recommendations from professional psychological services to support sobriety efforts for 2 of 2 residents (R2 and R3) reviewed for behavioral health needs.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess supervision needs and develop individualized person-centered interventions to identify and mitigate risks and hazards for residents when out in the community and upon subsequent return to the facility. This failure resulted in the risk of serious harm, injury, or impairment for 3 of 3 residents (R2, R3, R1) reviewed for safety. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident's advance directives was accurately and consistently documented in the resident's electronic health record (EHR) banner, Provider Order for Life-Sustaining Treatment (POLST), and physician orders to ensure the residents wishes would be followed in the event of a cardiac arrest. This resulted in immediate jeopardy for 1 of 33 residents (R84) whose code status was not accurately documented and was reviewed for advanced directives. The immediate jeopardy began on [DATE], when the POLST was signed indicating do not resuscitate (DNR) and a physician's order for R84 to have a full code status remained. The immediate jeopardy was identified on [DATE]. The assistant director of nursing (ADON) and director of nursing (DON) were notified of the immediate jeopardy on [DATE], at 7:40 p.m. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene cares (i.e., nail care, showering, facial hair removal, personal cares, dressing assistance) were offered and/or completed for 4 of 6 residents (R62, R37, R112, R64) reviewed for activities of daily living (ADLs) and whom were dependent on staff for such cares.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure developed skin conditions were identified, assessed and acted upon in a timely manner to promote healing and reduce the risk of complication (i.e., infection, worsening) for 2 of 2 residents (R103, R158) reviewed who had skin impairments.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement planned fall interventions for 1 of 2 residents (R125) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure assessed and ordered nutritional supplement interventions were followed for 1 of 1 resident (R18) reviewed for weight loss.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were consistently implemented in accordance with Centers for Disease Control (CDC) recommendations to reduce the risk of infection for 2 of 3 residents (R38, R25); and failed to ensure appropriate hand hygiene was completed during provision of personal care for 1 of 4 residents (R25) whose cares were observed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure complaint investigations for 2024 and 2025 and any plans of correction in effect with respect to the facility, and posting of notice of availability of such reports were posted in areas of the facility that were prominent and accessible to the public. This had the potential to affect all 155 residents, families and visitors who may have wished to review the information.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents who required assistance during mealtime on a locked dementia unit had a dignified dining experience.

Inspectors wroteDuring observation and interview, the facility failed to ensure resident records that contained private, medical, and personal information were not accessible to unauthorized personnel. This had the potential to affect all 72 residents of the second and third floor whose personal information was listed on exposed care sheets.

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff had not taken unauthorized pictures without consent for 1 of 4 residents (R4) reviewed for abuse. This had the potential for mental abuse using a reasonable person concept.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of staff to resident abuse for 2 of 4 residents (R1 and R4) reviewed involving 1 of 1 contracted staff (certified occupational therapy assistant (COTA)-A)).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure routine bathing, nail care and/or shaving assistance was offered or provided for 4 of 5 residents (R20, R35, R52, and R102) reviewed for activities of daily living, who were dependent of staff for assistance with bathing and/or grooming.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure routine dental needs were evaluated and, if needed, acted upon or addressed timely to promote oral hygiene for 4 of 5 residents (R26, R68, R92 and R102) reviewed for dental care.

Inspectors wroteBased on interview and document review, the facility failed to offer or provide the pneumococcal vaccine to 2 of 5 residents (R20 and R76) reviewed for immunizations. The facility further failed to offer or provide shared clinical decision making on the pneumococcal vaccine for 2 of 5 residents (R35 and R46) reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure the resident and/or resident representative participated in care conferences for the care planning process and development of care plan interventions for 1 of 1 residents (R82) reviewed for participation of care planning.

Inspectors wroteBased on observation, interview, and document review, the facility failed to accommodate resident needs by ensuring the call light was accessible for 3 of 3 residents (R96, R114 and R10) reviewed for call lights.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with the potential for inaccurate federal reimbursement and resident care planning, assessment and potential interventions needed for 2 of 2 residents (R26, R68) reviewed for MDS accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 1 of 1 residents (R7) reviewed for lymphedema (localized swelling caused by compromised lymphatic system) care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively reassess and, if needed, develop interventions to ensure a developed skin condition was resolved after initial treatment was completed for 1 of 1 resident (R71) observed to have a non-pressure skin impairment on their feet. In addition, the facility failed to identify and, if needed, ensure consistently elevated blood glucose levels were assessed or acted upon to reduce the risk of complication for 1 of 2 residents (R26) reviewed for diabetes management.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a range of motion (ROM) restorative program was completed for 1 of 1 resident (R46) who was on a ROM program to prevent contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff that prevents normal movement of a joint or other body part.) Additionally, the facility failed to ensure a recommended splint application was completed and reassessed as needed to treat current contractures and prevent worsening contractures for 2 of 2 residents (R19 and R68) reviewed who had contractures of the hands.

Inspectors wroteBased on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complication (i.e., missed orders, insufficient preparation for treatment) for 1 of 1 resident (R80) reviewed for dialysis care.

Inspectors wroteBased on interview and document review, the facility failed to act upon the consultant pharmacist's recommendation for 1 of 5 residents (R73) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure appropriate side effect monitoring (orthostatic blood pressure monitoring) was completed, in accordance with standards of care, related to antipsychotic medication use for 1 of 5 residents (R76) who had frequent falls and was reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident room walls were maintained in a clean, sanitary manner for 1 of 1 residents (R52) whose walls were soiled and in a state of disrepair. In addition, the facility failed to ensure 1 of 2 commerical ovens used in the main production kitchen was kept in the clean, sanitary manner to reduce the risk of particle cross-contamination. This had potential to affect all 138 residents, visitors, or staff who could consume food made using the device.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was available and worn by staff according to the Center for Disease Control and Prevention (CDC) and Minnesota Department of Health (MDH) guidelines for a facility in outbreak status for 7 residents (R2, R5, R6, R7, R8, R9 and R10). This had the potential to affect all 141 residents in the building. In addition, the facility failed to correctly identify 1 of 3 residents (R4) who required isolation precautions, failed to remove precautions for 1 of 3 residents (R2) reviewed for isolation precautions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure two of two residents (R1 and R2) reviewed remained free of physical and verbal abuse when the facility did not assess and care plan interventions between R1 and R2 with a history of threating behavior towards each other resulting in verbal and a physical altercation. Findings Include: On 10/30/23 at 9:07 a.m., the video footage from 10/16/23 at 4:02 p.m. was reviewed with the director of nursing (DON) and the assistant executive director. In the video, trained medication aide (TMA)-A was seen propelling R2 down the hallway and looking over her shoulder. R1 appeared around the corner propelling in his wheelchair. R1 and R2 appear to yell at each other, R2 activated the wheel locks on his wheelchair and TMA-A can no longer keep R1 and R2 separated. [...]

Inspectors wroteBased on interview and document review, the facility failed to immediately report abuse to the state agency, not later than two hours after an allegation is made for two of two residents (R1 and R2) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to complete investigations and thoroughly investigate into two incidents of verbal and physical abuse for two of two residents (R1, R2) reviewed for abuse.

Inspectors wroteBased on interviews, and records review, the facility failed to ensure provision of oxygen therapy according to orders for 1 of 1 resident (R1) reviewed for respiratory care. This resulted in harm for R1 whose saturation levels were 65% after not receiving continuous oxygen as ordered by physician and had to call Emergency Services herself because the facility failed to respond to her call light ( 2 hours and 15 minutes) when she became short of breath.