Providence Child Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure residents with limited range of motion received necessary equipment to prevent a further decrease in range of motion for 1 of 1 sampled resident (#3) reviewed for position and mobility. This placed residents at risk for worsening contractures. Findings include: Resident 3 was admitted to the facility in 2017 with diagnoses including contracture of multiple joints. Resident 3's 2/14/24 Quarterly MDS indicated the resident rarely/never made decisions, was dependent for all ADLs and experienced upper extremity impairment on both sides. A 3/6/24 Pediatric Physical Therapy Treatment Note indicated Resident 3 utilized hand splints. Resident 3's current HOB (Head of Bed) Care Plan directed the resident to wear hand splints when up in her/his wheelchair. Random observations of Resident 3 on 4/15/24 and 4/16/24 between 10:14 AM and 3:49 PM revealed the resident was up in her/his wheelchair without hand splints. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to accurately document and display the DCSDR (Direct Care Staff Daily Report) in a prominent place readily accessible to residents and visitors for 33 of 33 days reviewed for staffing and for 2 of 2 units. This placed residents and visitors at risk for being uninformed of available staff and hours worked by facility staff. Findings include: Random observations from 1/23/23 through 1/26/23 revealed the DCSDR forms on the unit downstairs were posted in a hallway adjacent to the entrance not visible to the public and the form was sideways. The DCSDR forms were blank or inaccurate and missing census, current staff and hours worked. The upstairs unit had a DCSDR posted outside the medication storage room and the forms were inaccurate, dated incorrectly, missing daily census, number of working staff and hours worked. A review of the two separate DCSDR's, dated from 12/25/22 through 1/26/23 revealed 33 instances where the forms did not indicate the same information for both units and portions of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview it was determined the facility failed to ensure residents were provided with the opportunity to develop a Resident Council for 1 of 2 residential units (the adult unit) reviewed for Resident Council. This placed residents at risk for a lack of participation in group discussions regarding facility policies, procedures and resident rights. Findings include: The adult unit of the faciity had a census of eleven. Four of the eleven residents resided on the unit longer than 6 months. On 1/23/23 at 10:36 AM Staff 3 (DNS) stated the adult residential unit did not have a Resident Council. On 1/27/23 at 3:27 PM Staff 1 (Administrator) stated the adult unit did not have a Resident Council.

Based on observation, interview and record review it was determined the facility failed to ensure residents' personal information was not visible to the public for 1 of 2 resident care units. This placed residents at risk for unprotected personal heath information. Findings include: Observations from 1/23/23 to 1/27/23 revealed the presence of a large dry erase board in the main area of the adult care unit visible to all staff, residents and visitors. The board had documentation of room number and initials of each resident with care notes such as transfer status, appointments, hospice, dialysis, and behaviors. On 1/26/23 at 10:02 AM Staff 8 (RN) confirmed the facility utilized the white board as a means of communication for all staff and it was helpful when agency staff worked on the floor. Staff 8 stated it was easier than sifting through the electronic record to locate the care plan which was not easily accessible. On 1/27/23 at 9:17 AM Staff 6 (RN) indicated the facility had discussed options other than the white board for direct care communication but had not implemented an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to thoroughly investigate falls for 1 of 2 sampled residents (#8) reviewed for accidents. This placed residents at risk for unmet needs. Findings include: Resident 8 admitted in 5/2022 with diagnoses including Alzheimer's disease and a history of falls. Fall investigations revealed the following: *Fall #1: -On 6/25/22 Staff 23 (Former LPN) heard a noise from Resident 8's room and found the resident with her/his back to the toilet in a seated position on the floor. Resident 8 had a skin tear to the right elbow. Staff 16 (CNA) last toileted Resident 8 at 5:30 AM and Staff 16 indicated he assisted her/him to the bathroom roughly six times throughout the night. The bed alarm was not on when Resident 8 was found on the floor with her/his back to the toilet. The investigation revealed Staff Resident 8 transferred herself/himself to the bathroom unassisted however, Staff 16 forgot to reset the bed alarm after taking Resident 8 to the bathroom at 5:30 AM. Resident 8 had no attempts to get out of bed prior to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to assure a Level I PASARR (Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability) was completed for 1 of 2 sampled residents (#10) reviewed for PASARR. This placed residents at risk for inappropriate placement in a nursing facility and a lack of needed services. Findings include: Resident 10 was admitted to the facility in 10/2020 with diagnoses including Lennox-Gastaut syndrome (a seizure disorder) and cerebral palsy. A review of the resident's electronic health record revealed Resident 10 was admitted for long term care in 10/2020 without the completion of a screening Level I PASARR. On 1/25/23 at 8:58 AM Staff 2 (DNS) stated an emergency suspension of PASARR's was in effect at the time of Resident 10's admission into long term care and was not required. On 1/25/23 at 3:57 PM Staff 5 (Administrative Assistant) stated the facility attempted to obtain a Level I PASARR for Resident 10 on 9/28/20. On 1/27/23 at 10:14 AM, Staff 3 (DNS) and Staff 5 confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on and interview and record review it was determined the facility failed to ensure a bowel protocol was implemented for 1 of 5 sampled residents (#30) reviewed for medications. This placed residents at risk for constipation. Findings include: Resident 30 was admitted to the facility in 12/2022 with diagnoses including hydrocephalus (a brain disorder in which excess fluid accumulates in the non-fluid chambers of the brain), diabetes and schizoaffective disorder. Resident 30's 1/2023 physician orders instructed staff to administer the following: - polyethylene glycol (Miralax) powder for constipation daily as needed starting on 12/28/22; - senna (Senokot) tablet for constipation two times daily as needed starting on 12/28/22. Resident 30's 1/2023 bowel tracking revealed she/he had no bowel movement for four consecutive days (1/10, 1/11, 1/12 and 1/13/23). Resident 30 had a bowel movement on 1/14/23 and then no bowel movement for five consecutive days (1/15, 1/16, 1/17, 1/18 and 1/19/23). Resident 30's 1/2023 MAR revealed no medication was administered for constipation in 1/2023.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure fall safety measures were in place for 1 of 2 sampled residents (#8) reviewed for accidents. This placed residents at risk for increased falls. Findings include: Resident 8 admitted in 5/2022 with diagnoses including Alzheimer's disease and a history of falls. Fall investigations revealed the following: *Fall #1 on 6/25/22: -Staff 23 (Former LPN) heard a noise from Resident 8's room and found her/his back to the toilet in a seated position on the floor. Resident 8 had a skin tear to the right elbow. Staff 16 (CNA) last toileted Resident 8 at 5:30 AM and Staff 16 indicated he assisted her/him to the bathroom roughly six times throughout the night. The bed alarm was not on when Resident 8 was found on the floor with her/his back to the toilet. The investigation revealed Resident 8 self-transferred herself/himself to the bathroom however Staff 16 forgot to reset the bed alarm after taking Resident 8 to the bathroom at 5:30 AM. Resident 8 had no attempts to get out of bed prior to the incident. No…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to have a contract with the dialysis provider for 1 of 1 sampled resident (#83) reviewed for dialysis services. This placed the resident at risk for unmet needs. Findings Include: Resident 83 was admitted to the facility in 1/2023 with diagnoses including end-stage renal disease requiring dialysis. Resident 83 received dialysis three days each week. On 1/27/23 at 3:27 PM Staff 1 (Administrator) confirmed the facility did not have a contract with the dialysis clinic that served Resident 83. She stated the facility had no contracts with any other dialysis facilities and would need to develop those for future needs.

Based on observation, interview and record review the facility failed to provide pharmaceutical service to ensure accurate acquiring, receiving and dispensing of medications for 2 of 5 sampled residents (#s 8 and 30) reviewed for medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 8 admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease and a pelvic fracture. a. A physician order start date on 11/2/22 directed staff to administer Tylenol two tablets three times daily for pain. The 12/2022 MAR revealed the following: -12/31/22 at 9:22 AM and 2:06 PM Tylenol was not available. b. A physician order start date on 1/3/23, (a new order was placed approximately every seven days) 1/7/23, 1/14/23 and 1/21/23 directed staff to apply miconazole (antifungal medication) cream twice daily following perineal care. Ensure groin area was thoroughly dried prior to application of miconazole to her/his groin area bilaterally for Resident 8's rash. The 1/2023 MAR revealed the following: -1/3/23 at 9:25 AM indicated not administered at 8:26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless deemed appropriate by the attending physician for 1 of 5 sampled residents (#23) reviewed for medications. This placed residents at risk for receiving unnecessary medications and adverse side effects. Findings include: Resident 23 admitted to the facility in 11/2022 with diagnoses including stroke and anxiety. A physician order start date of 11/27/22 directed staff to administer prochlorperazine (anti-anxiety and used to control severe nausea and vomiting) PRN for nausea. A Pharmacist Consult Report dated 12/8/22 and 1/25/23 revealed prochlorperazine was an antipsychotic and required a 14-day review/renewal. The 12/23/22 MAR revealed Resident 23 was administered prochlorperazine for nausea. A review of Resident 23's revealed no written rationale or indication of ongoing use of the prochlorperazine by her/his physician after the 11/27/22 start date (58 days). On 1/26/23 at 03:05 PM Staff 9 (Pharmacist) stated he completed monthly chart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to obtain therapy services for 1 of 1 sampled residents (#23) reviewed for therapy services. This placed residents at risk for a decline in functional abilities. Findings include: Resident 23 re-admitted to the facility in 11/2022 with diagnoses including stroke and anxiety. A physician order on 12/29/22 directed staff to request an evaluation and treatment for OT and PT. A Communication Result Report (a fax document) dated 1/10/23 (12 days later) requested PT and OT from Staff 7 (Administrator Coordinator/Care Manager). On 1/23/23 at 12:15 PM Resident 23 stated she/he was frustrated because she/he was not working with therapy services. On 1/26/23 at 10:18 AM Staff 8 (RN) stated Resident 23 was upset because she/he was not provided PT or OT. Staff 8 stated he reported his concerns to Staff 7 and she thought it would be a good idea to initiate therapy services. On 1/26/23 at 11:04 AM Staff 7 acknowledged Resident 23 requested PT and OT in 12/2022 and the physician initiated the orders. Staff 7 stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.