Providence Place

In the surveyor’s words

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

• Immediate jeopardy, patternF812Jun 25, 2021

  Based on observation, interview and document review, the facility failed to properly store milk at the appropriate temperature, below 41 degrees Fahrenheit (F), to ensure food safety and served this milk to 8 of 8 residents (R13, R17, R70, R100, R124, R137, R145, and R159) who consumed the milk. This had the potential to affect 119 out of 165 residents who received milk from the main kitchen walk in cooler. In addition, the facility failed to discard time-temperature-control for safety (TCS) food within seven days for food safety. The IJ began on 6/23/21, at 6:40 a.m. […]

• Immediate jeopardy, isolatedF689Apr 14, 2025

  Based 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. The immediate jeopardy began on 2/27/25 when the facility failed to ensure a systematic process of an individualized community safety assessment to identify potential risks or establish prevention strategies to ensure resident safety for R2 who had vascular dementia and required supervision, R3 who had significant current alcoholism with impaired insight, judment,… […]

• Immediate jeopardy, isolatedF578Feb 27, 2025

  Based 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]. […]

• Immediate jeopardy, isolatedF684Apr 13, 2022

  Based on interview on document review, the facility failed to accurately assess and review interventions placed for 1 of 3 residents (R1) reviewed for change in condition. This resulted in a delay of providing oxygen services and emergent care for R1. The deficiency was identified as past non-compliance and issued at Immediate Jeopardy (IJ). The IJ began on 3/30/22, when the facility failed to assess R1 for [CONDITION(S)] (low oxygen saturations) after R1 required continued monitoring after a change in condition was recognized and R1 was hospitalized . The administrator was notified of the IJ on 4/13/22 at 2:00 p.m. The facility had implemented immediate corrective action on 3/31/22 to prevent recurrence, so the IJ was issued at past none compliance. […]

• Actual harm, isolatedF695Oct 2, 2023

  Based 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. Findings include: R1's order summary report (OSR) as of 9/29/23, listed R1's diagnoses including history of sudden cardiac arrest, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and chronic obstructive pulmonary disease. […]