Mary's Meadow at Providence Place

In the surveyor’s words

From the most serious findings on record at Mary's Meadow at Providence Place, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Aug 27, 2025

  Based on record review and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse's Aides (CNA) that the RN was responsible for overseeing with provision of resident care.Specifically, the facility failed to have an RN working at least eight consecutive hours over a 24-hour period on 8/24/25.Findings include:Review of the 8/23/25 and 8/24/25 nursing schedule indicated an RN was scheduled to work on 8/23/25 from 7:00 A.M. until 3:00 P.M. […]

• No harm, potential for more than minimal, patternF868Jul 10, 2023

  Based on record review and interview, the facility failed to ensure all required staff members attended the scheduled quarterly Quality Assurance Performance Improvement (QAPI) meeting, as required. Specifically, the facility Infection Preventionist (IP) failed to attend three of the last four quarterly QAPI meetings. Findings Include: Review of the facility policy titled Mission Driven Quality Assurance and Performance Improvement Plan/Policy (QAPI), revised July 2023 indicated the following: -Committee membership includes the Medical Director, the Administrator, Director of Nursing, Social Services, Dietary Services, Activities, Pastoral Care, Environmental Services, Infection Preventionist, and other department managers as determined . […]

• No harm, potential for more than minimal, isolatedF580Aug 27, 2025

  Based on interview and record review, the facility failed to notify the Physician of a significant change in condition for one Resident (#1), out of a total sample of 12 residents. Specifically, the facility failed to notify Resident #1's Physician of a blood glucose level of greater than 350 milligrams per deciliter (mg/dl), as ordered.Findings include:Resident #1 was admitted to the facility in February 2020 with diagnoses that included Type 2 Diabetes Mellitus Without Complications and Atherosclerotic Heart Disease.Review of the Minimum Data Set (MDS) Assessment, dated 5/26/25, indicated Resident #1 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of a total possible score of 15.Review of the active Physician's Orders, dated 8/1/25,… […]

• No harm, potential for more than minimal, isolatedF761Aug 27, 2025

  Based on observation and interview, the facility failed to ensure that medications were stored in a safe and secure manner for one unit (Hillside Unit), out of a total of four units. Specifically, the facility failed to ensure that two blister pack medication cards containing 30 tablets of Metoprolol 50 milligrams (mg) (a medication used to treat heart and circulatory conditions) each were not stored on the counter at an unlocked nurses' station where the medications were readily accessible to unauthorized individuals.Findings include:Review of the undated facility policy titled Medication Storage In The Facility indicated the following:-Medications and biologicals are stored safely, securely, and properly following manufacturers' recommendations or those of the supplier. […]

• No harm, potential for more than minimal, isolatedF554Jul 10, 2023

  Based on observations, interview, and record review, the facility failed to assess one Resident's (#138) out of a total sample of 12 residents, ability to safely self-administer medications. Findings include: Review of the facility's policy for self-administration of medications, undated, included the following: - It is the policy of this facility that individual residents may self-administer medications if they indicate a desire to do so, and the interdisciplinary team (IDT), including the resident believe this is a safe practice. - If the resident has an order to keep medication at bedside, the facility must complete a Self-Administration of Medications screen. […]