Divine Providence Community Home

In the surveyor’s words

From the most serious findings on record at Divine Providence Community Home, in the surveyor’s own words.

• Actual harm, isolatedF689May 10, 2024

  Based on interview and record review the facility failed to use the appropriate type of mechanical lift sling according to the care plan for 1 of 3 residents (R1) reviewed for mechanical lift transfers. This resulted in harm when R1 was transferred with with a toileting sling resulting in subsequent pain, brusing and diagnosed humoral fracture to left arm. Findings include: A facility reported incident (FRI) submitted to the State Agency on 5/6/24, indicated R1 had an unexplained injury that staff became aware of on 5/4/24 when a nursing assistant (NA) reported R1 had dark black and blue bruising on her upper arm. R1 was sent to the hospital for further evaluation. […]

• Actual harm, isolatedF686Nov 9, 2022

  Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 3 residents (R1) reviewed who was at risk for pressure ulcer development. The facility's failure resulted in R1 sustaining harm when the resident developed a Stage IV (extend into the muscle, tendon, ligament, cartilage or even bone) pressure ulcer to the sacral/coccyx (triangular bone found between end of lumbar 5 of the spine and coccyx (end of spine area) area. […]

• No harm, potential for more than minimal, widespreadF865Apr 15, 2026

  Based on interview and document review, the facility failed to ensure data submitted to the QAPI committee for 4 of 4 quarters submitted and reviewed, was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 47 residents. Refer to F657 and F880. Findings include: Review of the QAPI meeting minutes submitted for review identified for review of the past 4 Quarters of QAPI meeting minutes identified review of each quarter is as follows: Quarter 1 (April 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, dietary manager, facility director, vice president, maintenance supervisor, the administrator, and social services attended. […]

• No harm, potential for more than minimal, widespreadF880Apr 15, 2026

  Based on interview and document review, the facility failed to have a system for employee surveillance based on national standards or identify specific criteria used in determining staff return to work (RTW) for 3 of 5 sampled staff (nurse aide (NA)-A, NA-B, and trained medication aide (TMA)-A).Findings include: Interview, employee surveillance review, and staff timecard punch review on 4/15/26 at 12:18 p.m., with registered nurse (RN)-A identified she is the interim infection preventionist (IP) while the IP was on vacation. When staff called in sick, facility process only dictated a return to work that was 3 days or longer required a physician Return to Work (RTW) note. […]

• No harm, potential for more than minimal, widespreadF880Nov 9, 2022

  Based on observation, interview and document review, the facility failed to ensure use of personal protective equipment (PPE) was implemented to prevent the spread of Covid-19 per guidance by the Centers for Disease Control (CDC) when during a Covid-19 outbreak, residents and visitors were observed not wearing masks, and staff not wearing masks correctly. Further, the facility failed to ensure PPE and transmission based precautions (TPB) were used in accordance with the CDC guidance for Covid-19 for 1 of 1 resident (R20) reviewed for transmission-based precautions (TBP). Findings include: A sign was observed on 11/9/22, at approximately 12 noon, at the entrance to the facility, taped to the Covid-19 check-in station that indicated the facility was in Covid-19 outbreak status. […]