A list of the most recent deficiencies for Providence Extended Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-14 | 2023-07-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-14 | 2023-05-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-04-14 | 2023-05-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-14 | 2023-05-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-14 | 2023-05-29 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-04-14 | 2023-05-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-04-14 | 2023-05-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-14 | 2023-05-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-14 | 2023-05-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-14 | 2023-05-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-14 | 2023-05-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-04-14 | 2023-05-29 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-04-14 | 2023-05-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-14 | 2023-05-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-14 | 2023-05-29 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-01-21 | 2022-03-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-01-21 | 2022-03-03 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-01-21 | 2022-03-03 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-01-21 | 2022-03-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-29 | 2022-02-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-29 | 2022-02-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-12-29 | 2022-02-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-12-29 | 2022-02-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-29 | 2022-02-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-29 | 2022-02-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-12-29 | 2022-02-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-29 | 2022-02-12 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-29 | 2022-02-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-29 | 2022-02-12 | N |
| Post nurse staffing information every day. | Health | 2021-12-29 | 2022-02-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-29 | 2022-02-12 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-12-29 | 2022-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-29 | 2022-02-12 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-29 | 2022-02-12 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-12-29 | 2022-02-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-12-29 | 2022-02-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-29 | 2022-02-12 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-12-29 | 2022-02-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-29 | 2022-02-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-29 | 2022-02-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-29 | 2022-02-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-29 | 2022-02-12 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-21 | 2022-02-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-21 | 2022-02-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-21 | 2022-02-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-21 | 2022-02-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-21 | 2022-02-03 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-06-24 | 2019-08-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-24 | 2019-08-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-24 | 2019-08-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-06-24 | 2019-08-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-06-24 | 2019-08-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-06-24 | 2019-08-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-24 | 2019-08-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-24 | 2019-08-08 | N |
| Keep all essential equipment working safely. | Health | 2019-06-24 | 2019-08-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-27 | 2019-08-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-27 | 2019-08-08 | N |
