A list of the most recent deficiencies for Providence Health and Rehab Center. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-02-06 | 2024-02-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-18 | 2024-02-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-18 | 2024-02-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-18 | 2024-02-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-18 | 2024-02-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-18 | 2024-02-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-05 | 2023-11-10 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-05 | 2023-11-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-05 | 2023-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-05 | 2023-11-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-05 | 2023-11-10 | 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 | 2023-10-05 | 2023-11-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-05 | 2023-11-10 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-10-05 | 2023-11-10 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-05 | 2023-11-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-05 | 2023-11-10 | 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 | 2023-10-05 | 2023-11-10 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-10-05 | 2023-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-05 | 2023-11-10 | N |
| Dispose of garbage and refuse properly. | Health | 2023-10-05 | 2023-11-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-05 | 2023-11-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-05 | 2023-11-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-03 | 2023-11-10 | 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 | 2023-05-04 | 2023-06-06 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-05-04 | 2023-06-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-28 | 2022-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-28 | 2022-11-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-28 | 2022-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-25 | 2022-11-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-25 | 2022-11-22 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-10-25 | 2022-11-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-25 | 2022-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-22 | 2022-09-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-29 | 2021-12-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-29 | 2021-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-29 | 2021-12-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-29 | 2021-12-22 | 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 | 2021-10-29 | 2021-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-27 | 2021-12-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-27 | 2021-12-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-27 | 2021-12-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-27 | 2021-12-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-27 | 2021-12-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-03 | Not Fixed | Y |
