Providence Care Center

In the surveyor’s words

From the most serious findings on record at Providence Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 26, 2026

  Based on medical record review, staff interviews, hospital record review, and review of facility policy, the facility failed to accurately and timely assess an acute change in condition (lack of assessments), failed to collaborate with the surgeon and failed to timely recognize significant changes in condition for a post-surgical resident resulting in delayed interventions. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcomes on 06/04/26 at 12:02 P.M. […]

• Immediate jeopardy, isolatedF760Jun 26, 2026

  Based on medical record review, staff interviews, hospital record review and review of facility policy, the facility failed to ensure Eliquis (an oral anticoagulant medication used to prevent and treat blood clots) was administered as ordered by the physician. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcomes on 06/04/26 at 12:02 P.M. when Resident #100 was seen by Vascular Surgeon #250 and the left lower extremity was assessed to have palpable femoral pulses bilaterally with no appreciable flow detected in the distal left lower extremity with no distal pulses palpable, absent sensation over the left foot with preserved sensation at a more proximal level, and clammy skin with mottled discoloration. […]

• Immediate jeopardy, isolatedF678Dec 13, 2022

  Based on medical record review, staff interviews, review of the facility investigation, review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation, review of the American Heart Association Journal, review of a job description for Licensed Practical Nurses (LPN), and review of cardiopulmonary resuscitation (CPR) certifications, the facility failed to timely initiate CPR or contact emergency medical services (EMS) for one resident (Resident #03) found unresponsive, without a pulse or blood pressure, and who was identified as a Full Code status. […]

• Immediate jeopardy, isolatedF689Mar 31, 2021

  Based on medical record review, staff interview, review of the police report, review of the facility policy for missing residents, and review of the facility investigation, the facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious injury when Resident #04, who had history of exit seeking behaviors and dementia, left the facility unknown to staff and was found one tenth of a mile from the facility by a civilian when Resident #04 walked into a local business and the employees notified emergency services. A facility staff entered the front entrance by accessing the digital keypad which in turn disarmed the Wanderguard alarm system. […]

• Actual harm, isolatedF689Jun 13, 2021

  Based on medical record review, staff interview, review of the Self-Reported Incident (SRI), review of the facility investigation, review of the manufacturers recommendations, and policy review, the facility failed to ensure mechanical lift equipment was maintained in a safe working condition and failed to ensure residents received appropriate supervision during mechanical lift transfers from the wheelchair to the bed. This resulted in Actual Harm when State tested Nursing Assistant (STNA) #100 failed to ensure there were two staff members present for the transfer using the mechanical lift when the lift suffered mechanical failure resulting in Resident #01 descending three feet to the floor and subsequently suffered a left sacral fracture. […]