Providence Point Healthcare Residence

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of instructions, for four of eight residents reviewed (Residents R4, R5, R15 and R25). Findings Include: A review of the facility policy Advance Directives last reviewed 2/26/25, indicated it's the policy of this facility that each resident has the right to formulate and Advance Directive. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual (RAI) and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS - periodic assessment of resident care needs) assessments were accurate and fully completed for six of fifteen residents (Resident R15, R17, R20, R25, R26, and R27). Findings include: The Long-Term Care Facility RAI User's Manual, which gives instructions for completing the MDS dated [DATE], indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and staff interviews, it was determined that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population, outcome of the facility assessment, or non-common procedures for one of six residents (Resident R92) Findings include: Review of the manufacturer's instructions dated February 2016, for the Breg Polar Care Cube is a cold therapy machine that works by filling a cooler with ice and water. Then, a hose circulates that ice water through a pad that's attached to your body. This can provide motorized cold treatment for roughly eight hours. The instructions further stated, Use only according to your practitioner's instructions regarding the frequency and duration of the cold application. Inspect the skin under the cold therapy pad as prescribed, typically every one to two hours. DO NOT RUN PUMP WITHOUT WATER! The pump in this unit is designed to run with water. Running the unit…

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 review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain call light tubes were in reach for one of four residents with limited upper extremity range of motion or contractures (Resident R5). Findings include: The facility policy Call Lights dated 2/26/25, indicated before leaving a resident's room, all staff must make sure that the resident's call light tube is within reach. Review of Resident R5's clinical record indicated admission to the facility on 9/13/20. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/25/25, indicated diagnoses of stroke, diabetes, and heart disease. Review of Section GG: Functional Abilities, indicated that Resident R5 has range of motion impairment on both sides of her upper and lower body. Review of therapy notes 3/11/25, indicated resident R5 to have an evaluation for appropriate interventions for the resident's contractures. Review of providers orders on 4/17/25, revealed orders for bilateral palm guards for both hands each shift with…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and resident and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for one of six residents (Resident R92). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the facility policy, Resident's Rights to Personal Privacy dated 2/26/25, indicated that the facility will ensure the resident's rights to personal privacy and confidentiality of his/her personal and clinical records. Review of…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary psychotropic drugs used without adequate indications for use for one of three residents. (Resident R92). Findings include: Review of the facility, Psychotropic Medication Policy dated 2/26/25, indicated; Psychotropic medication will be given only for a specific diagnosed and documented condition. Review of Resident R10's admission record indicated she was initially admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS- periodic assessment of care needs) assessment dated [DATE], included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Centers for Medicare & Medicaid Services documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive, person-centered care plan with all requirements, when a comprehensive care plan is being utilized in place of a baseline care plan for one of six residents (Resident R92). Findings include: Review of Centers for Medicare & Medicaid Services, HHS § 483.21 indicated that the facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements set forth (Comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified). Review of the facility policy Care Plan Process dated 2/26/25, indicated that an individualized,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for two of eight residents (Residents R5 and R27). Findings include: Review of facility's policy Care Plan Process dated 2/26/25, indicated a change in the resident's condition requires immediate identification of problem and approaches to assist in managing the change. Staff members are responsible for updating the care plan as changes occur. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/25/25, indicated diagnoses of cerebrovascular disease (stroke), hypothyroidism (body doesn't make enough thyroid hormones), and aphasia (difficulty in communication). Review of therapy notes dated 3/11/25 indicated resident to have an evaluation for appropriate interventions for the resident's…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of manufacturer instructions, facility policy, facility documentation and staff interviews, it was determined that the facility failed to provide appropriate treatment and services related to the post-operative care of joint replacement for one of six residents (Resident R92). Findings include: Review of the manufacturer's instructions dated February 2016, for the Breg Polar Care Cube is a cold therapy machine that works by filling a cooler with ice and water. Then, a hose circulates that ice water through a pad that's attached to your body. This can provide motorized cold treatment for roughly eight hours. The instructions further stated, Use only according to your practitioner's instructions regarding the frequency and duration of the cold application. Inspect the skin under the cold therapy pad as prescribed, typically every one to two hours. DO NOT RUN PUMP WITHOUT WATER! The pump in this unit is designed to run with water. Running the unit without water will cause permanent damage 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights or act upon weight changes for two of six residents (Residents R10 and R21). Findings include: Review of the facility, Weight Policy dated 2/26/25, indicated it is the policy of the facility to obtain resident's weights in a routine systematic fashion to monitor nutritional status. Review of Resident R10's admission record indicated she was initially admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS- periodic assessment of care needs) assessment dated [DATE], included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and…

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 review of facility policy, observations, and staff interview, it was determined that the facility to make certain that medical supplies were properly stored and/or disposed of on one of two nursing units (Second-Floor Nursing Unit). Findings include: Review of the facility policy Storage of Medications dated 2/26/25, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. During an observation of the Second-Floor Nursing Unit medication room on 6/16/25, at 11:26 a.m. the following was observed: (2) IV Administration Set with an expiration date of 6/7/25. (1) IV Administration Set with an expiration date of 2/2/25. (5) IV Administration Set with an expiration date of 10/14/24. (2) Central Line Dressing Change with an expiration date of 5/31/25. (1) Central Line Dressing Change with an expiration date of 12/15/24. (4) Sterilux AMD gauze with an expiration date of 2/28/25. (2) Sterilux AMD gauze not in packaging. (24) Winged IV Catheter with an expiration date of 10/31/23. (2) IV…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide care to a resident who had not received scheduled medication for one of four residents (Resident R1). Findings include: Review of the facility policy Medication Administration dated May 2024, indicated the facility will administer all medications consistent with standard of care and prescribed by the physician/designee. Review of the facility policy Medication Incident Report dated May 2024, indicated the physician will be notified of a medication error and recommendations will be received. Review of the clinical record indicated Resident R1 was readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/22/24, included diagnoses of malnutrition (lack of sufficient nutrients in the body) and orthostatic hypotension (a sudden drop in blood pressure upon standing from a sitting or lying position). Review of Section C:…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, resident clinical records, documentation provided by the facility and staff interview, it was determined that the facility failed to ensure that a resident was free from neglect, which resulted in a skin tear requiring a treatment for one of four residents ( Resident R7). Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility policy Preventing Resident Abuse last reviewed on 5/24, indicated that residents will not be subject to physical, mental, etc. abuse. Annual training of all employees will be conducted to ensure the knowledge of the abuse policy. Policies and procedures have been developed to document the facilities philosophy regarding the elderly. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documents, clinical records, and staff interviews, it was determined that the facility failed to identify and investigate incidents of possible neglect and abuse for two of seven residents (Residents R7 and R28). Findings include: Review of the facility policy Preventing Resident Abuse, last reviewed May 2024, with a previous review date of May 2023, indicated that every complaint or allegation of resident abuse or neglect will be immediately reported to the Director of Nursing(DON) by the charge nurse and the DON will notify the Administrator The person receiving the report will make investigation a priority in order to protect the resident and gather data in a timely manner. Incidents and accidents are investigated at the time of the discovery. Review of the clinical record indicated that Resident R7 was admitted to the facility on [DATE], with diagnoses which included dementia with other behavioral disturbances, atrial fibrillation (irregular heart beat), a…

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.