Providence Health Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686May 16, 2025

  Based on observation, interview, and record review, the facility failed to ensure that staff assessed a resident with a pressure ulcer and implemented treatments which resulted in harm due to the pressure ulcer worsening from a stage 1 (non-blanchable red intact skin) to a stage 3 (full thickness skin loss where fat tissue may be visible) before pressure ulcer assessments and treatments were started for 1of 2 residents reviewed for pressure ulcers (Resident 16). Findings include: On 5/12/25 at 11:23 a.m., during an initial observation and interview Resident 16 indicated he had a sore area on his bottom. On 5/14/25 at 8:46 a.m., the medical record of Resident 16 was reviewed. […]

• Actual harm, isolatedF698Sep 21, 2021

  Based on observation, record review, and interview, the facility failed to ensure communication was received post [CONDITION(S)] (filters blood to rid the body of harmful wastes) from the [CONDITION(S)] center, post [CONDITION(S)] assessments were completed, care plans were revised, and assessments of an prostatic arteriovenous graft (used for [CONDITION(S)] treatment) site and an implanted permacath (a flexible tube inserted into a vein most commonly in the neck used for [CONDITION(S)] treatment) were completed which resulted in harm when the resident developed an infection to the graft site that led to the site opening and the resident losing one to two liters of blood, being hospitalized , and requiring a new graft placement for 1 of 1 residents reviewed for [CONDITION(S)] (Resident 6). […]

• No harm, potential for more than minimal, patternF812Mar 18, 2024

  Based on observation, interview, and record review, the facility failed to ensure beard restraints were worn in the kitchen serving area (on the skilled unit) and in the main kitchen food prep area for 2 of 2 kitchen observations. Findings include: 1. During an observation in the kitchen serving area (located on the skilled unit), on 3/11/24 at 11:40 a.m., the Dietary Director was placing whip cream on top of the vanilla and chocolate shakes. The Dietary Director was not wearing a beard restraint and his facial hair was exposed. 2. During an observation in the kitchen serving area, on 3/11/24 at 11:43 a.m., the Dietary Director was placing cinnamon pita chips onto 16 dessert plates from a serving pan. The Dietary Director was not wearing a beard restraint and his facial hair was exposed. […]

• No harm, potential for more than minimal, patternF565Feb 1, 2023

  A. Based on interview and record review, the facility failed to address grievances in a manner which could be tracked for 5 of 5 months reviewed for grievance resolutions of the Resident Council and the facility's grievance log. This potentially affected 63 of 63 residents who resided in the facility. B. Based on observation, interview, and record review, the facility failed to ensure a grievance provided during resident council was resolved for 1 of 1 resident reviewed for grievances (Resident 40). Findings include: A1. Resident Council minutes were provided by the Activity Director (AD) on 1/24/23 at 10:28 a.m. The minutes indicated the following concerns by the Resident Council: a. Cold food temperatures of the residents' meals b. […]

• No harm, potential for more than minimal, patternF689Feb 1, 2023

  Based on observation, interview, and record review, the facility failed to ensure an effective fall management program and failed to ensure fall interventions were personalized, implemented, and care planned for 4 of 4 residents reviewed for accidents (Residents 36, 31, 40, and 35). Findings include: 1. During an initial pool interview on 1/24/23 at 11:16 a.m., Resident 36 indicated she had multiple falls, but she was not sure when the last fall had occurred. Pointing to her head, she indicated she had pain in a bump on the back of her head and on her leg. The resident's private bathroom was observed to have pieces and strips of toilet paper on the floor around the toilet, and a clean brief on the sink with pieces torn out of it. Resident 36's record was reviewed on 1/27/23 at 1:24 p.m. […]