Inspection Reports for Providence Place
3720 23rd Ave S, Minneapolis, MN 55407, United States, MN, 55407
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 23, 2025, identified a deficiency related to the facility’s failure to include speech therapy recommendations for safe eating and swallowing in one resident’s care plan. Earlier inspections showed a pattern of deficiencies involving care planning, behavioral health care, infection control, resident safety, and abuse investigations. Prior complaints substantiated issues with inadequate supervision of residents in the community, failure to prevent and investigate abuse incidents, and lapses in medication management and respiratory care, some resulting in actual harm or immediate jeopardy. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history reflects ongoing challenges with individualized care planning and resident safety, with some recent findings continuing similar themes noted in prior reports.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
19.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
395% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
155 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Deficiencies: 1
Date: May 23, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the inclusion of interventions for safe eating and swallowing for residents.
Findings
The facility failed to include speech therapy recommendations for safe eating and swallowing, such as crushing medications and positioning strategies, in the care plan for one resident (R1) who had swallowing difficulties and was a choking risk. The care plan lacked timely updates to reflect these safety interventions despite documented orders and education.
Deficiencies (1)
Failure to develop and implement a complete care plan that includes interventions for safe eating and swallowing for resident R1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Worked with resident R1 on 2/14/25, administered crushed medications, and educated family and resident on safe eating positions. |
| SLP-A | Speech Language Pathologist | Provided evaluation and treatment recommendations for resident R1's swallowing difficulties. |
| ADON | Assistant Director of Nursing | Reviewed resident R1's care plan and verified that speech therapy recommendations were not included. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 30, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with behavioral health care requirements, specifically focusing on the development and implementation of individualized behavioral health care plans for residents with behavioral health needs.
Findings
The facility failed to develop and implement individualized behavioral health care plans utilizing recommendations from professional psychological services to support sobriety efforts for 2 of 2 residents reviewed (R2 and R3). Both residents had documented behavioral health needs including depression, substance use disorder, and cognitive impairments, and incidents involving unsupervised absences and hospitalizations were noted.
Deficiencies (1)
Failure to develop and implement individualized behavioral health care plans utilizing recommendations from professional psychological services to support sobriety efforts for residents R2 and R3.
Report Facts
Residents Affected: 2
Facility ID: 245271
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CLC-A | Community Life Coordinator | Interviewed regarding resident R2's participation in activities and awareness of psychological recommendations |
| DSS | Director of Social Services | Interviewed regarding resident R2's and R3's behaviors, hospitalizations, and awareness of psychological recommendations |
| PsyD | Psychologist with Doctoral degree | Provided psychological treatment and recommendations for resident R3 and discussed harm reduction program |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 14, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to comprehensively assess supervision needs and develop individualized interventions to mitigate risks for residents when out in the community and upon return, which posed immediate jeopardy to resident health or safety.
Complaint Details
The complaint investigation revealed that residents R2, R3, and R1 had multiple incidents of leaving the facility unsupervised, with R2 missing for up to 42 hours and multiple hospitalizations, R3 frequently intoxicated and unsupervised in the community, and R1 with substance abuse and cognitive impairments. The facility lacked comprehensive community safety assessments and interventions to ensure resident safety.
Findings
The facility failed to ensure a systematic process for individualized community safety assessments for residents with cognitive impairments and substance use disorders, resulting in multiple incidents of residents leaving unsupervised, missing for extended periods, and returning intoxicated or injured. The immediate jeopardy was identified and removed, but noncompliance remained at a lower severity level.
Deficiencies (1)
Failure 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.
Report Facts
Duration resident missing: 42.75
Hospitalization duration: 22
SLUMS score: 19
Blood alcohol level: 0.33
Blood alcohol level: 0.36
Elopement risk score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Interviewed regarding resident supervision and missing person protocols |
| OT-A | Occupational Therapist | Conducted cognitive assessments and discussed resident safety in community |
| NP-A | Nurse Practitioner | Interviewed about facility responsibility for assessing resident risk when leaving facility |
| Medical Director | Medical Director | Interviewed about resident leave process and cognitive assessments |
| LP-A | Licensed Psychologist | Performed SLUMS assessment and discussed comprehensive community safety assessments |
| DON | Director of Nursing | Interviewed about facility processes for resident supervision and missing person reporting |
Inspection Report
Routine
Census: 155
Deficiencies: 9
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, complaint investigations, advance directives, privacy, personal care, skin care, fall prevention, nutrition, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified dining experiences, inadequate posting of complaint investigation results, inaccurate documentation of advance directives causing immediate jeopardy, failure to maintain resident privacy, incomplete personal hygiene care, delayed identification and treatment of skin impairments, failure to implement fall prevention interventions, failure to provide ordered nutritional supplements, and inconsistent implementation of enhanced barrier precautions and hand hygiene.
Deficiencies (9)
Failed to ensure residents who required assistance during mealtime on a locked dementia unit had a dignified dining experience.
Failed to ensure complaint investigations and plans of correction were posted in accessible areas for residents and visitors.
Failed to ensure a resident's advance directives were accurately and consistently documented, resulting in immediate jeopardy.
Failed to keep residents' personal and medical records private and confidential.
Failed to ensure routine personal hygiene cares were offered and/or completed for residents dependent on staff.
Failed to ensure developed skin conditions were identified, assessed, and acted upon in a timely manner to promote healing and reduce risk of complications.
Failed to implement planned fall interventions for a resident with a history of falls.
Failed to ensure assessed and ordered nutritional supplement interventions were followed for a resident reviewed for weight loss.
Failed to ensure enhanced barrier precautions were consistently implemented and appropriate hand hygiene was completed during personal care.
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 155
Residents needing assistance with eating: 6
Residents needing assistance with eating: 5
Residents census: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Named in dignified dining experience deficiency and infection control observation |
| NA-N | Nursing Assistant | Named in dignified dining experience deficiency |
| NA-I | Nursing Assistant | Interviewed about dignified dining experience |
| LPN-E | Licensed Practical Nurse | Interviewed about dignified dining experience and advance directives |
| DON | Director of Nursing | Interviewed about dignified dining experience, complaint posting, advance directives, privacy, personal care, skin care, falls, nutrition, and infection control |
| ADON | Assistant Director of Nursing | Interviewed about advance directives, personal care, skin care, and falls |
| SSD | Social Services Director | Interviewed about complaint posting and advance directives |
| RN-C | Registered Nurse, Staff Development Coordinator and Infection Preventionist | Interviewed about advance directives and infection control |
| LPN-B | Licensed Practical Nurse | Interviewed about advance directives |
| LPN-A | Licensed Practical Nurse | Interviewed about advance directives |
| HUC-A | Health Unit Coordinator | Interviewed about advance directives |
| NP-A | Nurse Practitioner | Interviewed about advance directives |
| NA-B | Nursing Assistant | Interviewed about personal care |
| LPN-D | Licensed Practical Nurse | Interviewed about personal care and skin care |
| NA-C | Nursing Assistant | Interviewed about personal care and skin care |
| NA-H | Nursing Assistant | Interviewed about personal care |
| RN-E | Registered Nurse | Interviewed about personal care and skin care |
| NA-G | Nursing Assistant | Interviewed about personal care |
| RN-D | Registered Nurse | Interviewed about skin care |
| NA-O | Nursing Assistant | Interviewed about skin care |
| TMA-A | Trained Medication Assistant | Interviewed about fall interventions |
| NA-J | Nursing Assistant | Interviewed about fall interventions |
| LPN-E | Licensed Practical Nurse | Interviewed about fall interventions |
| RN-F | Registered Nurse | Interviewed about nutritional supplements |
| DA-A | Dietary Aide | Interviewed about nutritional supplements |
| NA-Q | Nursing Assistant | Interviewed about nutritional supplements |
| NA-R | Nursing Assistant | Interviewed about nutritional supplements |
| NA-H | Nursing Assistant | Interviewed about nutritional supplements |
| NA-D | Nursing Assistant | Observed and interviewed about infection control and enhanced barrier precautions |
| NA-E | Nursing Assistant | Observed and interviewed about infection control and enhanced barrier precautions |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, dignity, personal hygiene, infection control, and activities of daily living in a nursing home facility.
Findings
The facility was found deficient in ensuring residents received dignified dining experiences, adequate personal hygiene care including nail care, showering, and shaving assistance, and proper infection prevention practices including consistent use of enhanced barrier precautions and hand hygiene.
Deficiencies (3)
Failure to ensure residents who required assistance during mealtime on a locked dementia unit had a dignified dining experience, including inappropriate use of the term 'feeders'.
Failure to ensure routine personal hygiene cares (nail care, showering, facial hair removal, dressing assistance) were offered and/or completed for 4 of 6 residents reviewed for activities of daily living.
Failure to ensure enhanced barrier precautions were consistently implemented in accordance with CDC recommendations to reduce infection risk for residents with wounds or indwelling devices, and failure to ensure appropriate hand hygiene during personal care.
Report Facts
Residents needing assistance with eating: 6
Residents reviewed for personal hygiene deficiencies: 6
Residents affected by infection control deficiencies: 3
Nail length: 1
Residents with soiled or long nails observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Mentioned in relation to use of term 'feeders' and failure to perform hand hygiene during personal care. |
| NA-N | Nursing Assistant | Acknowledged inappropriate use of term 'feeders' during mealtime. |
| NA-B | Nursing Assistant | Interviewed regarding resident R62's personal hygiene and nail care. |
| LPN-E | Licensed Practical Nurse | Interviewed about dignity concerns and personal hygiene care including nail care and shaving. |
| DON | Director of Nursing | Agreed use of term 'feeders' was not dignified and discussed expectations for hygiene care. |
| ADON | Assistant Director of Nursing | Discussed expectations for hygiene care, nail care, showering, and clothing changes. |
| RN-C | Registered Nurse, Infection Preventionist | Verified infection control education and expectations for enhanced barrier precautions. |
| NA-D | Nursing Assistant | Observed not wearing gown during care requiring enhanced barrier precautions. |
| NA-E | Nursing Assistant | Observed not wearing gown during care requiring enhanced barrier precautions. |
| RN-F | Registered Nurse | Observed not wearing PPE during transfer of resident requiring enhanced barrier precautions. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to allegations of staff to resident abuse involving unauthorized photographs taken by a contracted therapy staff member (COTA-A) and failure to thoroughly investigate these allegations.
Complaint Details
The complaint involved allegations of staff to resident abuse by contracted therapy staff (COTA-A) involving residents R1 and R4. The investigation was incomplete as it did not address unauthorized photographs of R4 and did not include interviews with facility floor staff. The complaint was substantiated by findings of unauthorized photographs and inadequate investigation.
Findings
The facility failed to ensure staff did not take unauthorized pictures of a resident (R4), constituting potential mental abuse. Additionally, the facility failed to thoroughly investigate allegations of staff to resident abuse involving two residents (R1 and R4) and one contracted staff member (COTA-A). Facility policies on abuse and use of personal devices were reviewed, and interviews revealed gaps in investigation and policy enforcement.
Deficiencies (2)
Failed to protect residents from unauthorized photographs taken by staff, constituting potential mental abuse.
Failed to thoroughly investigate allegations of staff to resident abuse involving contracted therapy staff.
Report Facts
Residents reviewed for abuse: 4
Residents affected: 2
Date of Vulnerable Adult Evaluation: Jun 26, 2024
Date of text message with unauthorized photo: Sep 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| COTA-A | Contracted Therapy Staff (Certified Occupational Therapy Assistant) | Named in unauthorized photograph and abuse allegation |
| ED | Executive Director | Provided statements regarding investigation and photographs |
| AED | Assistant Executive Director | Provided statements regarding investigation and policy violation |
| G-A | Guardian | Provided statements regarding resident R4's cognition and reaction to incident |
Inspection Report
Routine
Deficiencies: 13
Date: Apr 4, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, dental care, immunizations, safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, inadequate accommodation of resident needs such as call light accessibility, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans for lymphedema, insufficient assistance with activities of daily living, failure to reassess and treat skin conditions, inadequate diabetes management, failure to ensure range of motion programs and splint applications, poor communication with dialysis clinic, failure to act on pharmacist recommendations, lack of side effect monitoring for antipsychotic medications, failure to provide timely dental care, incomplete immunization offerings, and maintenance and cleanliness issues in resident rooms and kitchen equipment.
Deficiencies (13)
Failed to ensure resident participation in care planning for 1 of 1 resident (R82).
Failed to accommodate resident needs by ensuring call light accessibility for 3 of 3 residents (R96, R114, R10).
Failed to ensure accurate Minimum Data Set (MDS) coding for 2 of 2 residents (R26, R68).
Failed to develop and implement a comprehensive care plan for lymphedema care for 1 of 1 resident (R7).
Failed to provide routine bathing, nail care, and shaving assistance for 4 of 5 residents (R20, R35, R52, R102).
Failed to reassess and treat a non-pressure skin impairment and failed to monitor elevated blood glucose levels for 2 residents (R71, R26).
Failed to ensure range of motion restorative program completion and splint application for residents with contractures (R46, R19, R68).
Failed to maintain appropriate communication and collaboration with outside dialysis clinic for 1 resident (R80).
Failed to act upon consultant pharmacist's recommendation regarding unnecessary medication for 1 of 5 residents (R73).
Failed to ensure appropriate side effect monitoring (orthostatic blood pressure) for antipsychotic medication for 1 of 5 residents (R76).
Failed to ensure routine dental needs were evaluated and addressed timely for 4 of 5 residents (R26, R68, R92, R102).
Failed to offer or provide pneumococcal vaccine or shared clinical decision making for 4 of 5 residents (R20, R76, R35, R46).
Failed to maintain resident room walls in a clean, sanitary manner and failed to keep commercial kitchen oven clean to reduce cross-contamination risk.
Report Facts
Blood sugar readings above 400: 52
Residents reviewed for dental care: 5
Residents reviewed for immunizations: 5
Residents reviewed for bathing and grooming: 5
Residents reviewed for antipsychotic medication monitoring: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW-A | Social Worker | Stated today was first time anyone offered to set up a comprehensive dental appointment for R68. |
| LPN-A | Licensed Practical Nurse | Reviewed R73 medication order and stated diagnosis was missing. |
| DON | Director of Nursing | Reviewed medication regimen reviews and confirmed diagnosis was not added for R73; stated expectations for monitoring and care plans. |
| CP | Consultant Pharmacist | Performed monthly medication regimen reviews and recommended updating diagnosis for R73 medication. |
| RN-B | Registered Nurse Clinical Director | Reviewed R71's skin condition and dialysis communication issues; stated expectations for monitoring and follow-up. |
| DOR | Director of Rehab | Discussed restorative programs and splint application for residents R19, R46, and R68. |
| NA-C | Nursing Assistant | Verified long, dirty nails for residents R20 and R52 and intent to trim. |
| NA-F | Nursing Assistant | Stated R68 never wears splint and had stopped offering it due to pain. |
| RN-A | Registered Nurse | Explained dialysis communication process and issues with incomplete forms for R80. |
| HUC-D | Health Unit Coordinator | Described dialysis appointment setup and lack of awareness of dialysis communication form. |
| IP | Infection Preventionist | Discussed pneumococcal vaccine implementation barriers. |
| NSD | Nutrition Service Director | Discussed kitchen oven cleaning responsibilities and schedules. |
| M-A | Maintenance | Verified notification process for repairs and status of resident room wall repairs. |
| HD | Housekeeping Director | Verified cleaning schedules and last deep cleaning of resident room. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 4, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding resident care, specifically focusing on whether call lights were accessible to residents.
Findings
The facility failed to ensure that call lights were accessible to 3 residents (R96, R114, and R10). Observations and interviews revealed that call lights were often out of reach or unplugged, posing a risk to resident safety and dignity.
Deficiencies (1)
Facility failed to accommodate resident needs by ensuring the call light was accessible for 3 of 3 residents reviewed for call lights.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| TMA-A | Trained Medication Aide | Stated resident call lights must be in reach and commented on call light accessibility for R96 and R114. |
| LPN-A | Licensed Practical Nurse | Stated call lights should be in reach of residents including R96 and R114. |
| DON | Director of Nursing | Stated importance of call lights being in reach of all residents and noted lack of call light or dignity policy. |
| FM-A | Family Member | Believed R114 could use the call light if it was in her hand and close by. |
| NA-E | Nursing Assistant | Stated R10 could use the call light and effectively communicate needs but was unsure why it was not used on one occasion. |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 3
Date: Nov 16, 2023
Visit Reason
The inspection was conducted due to an outbreak investigation triggered by COVID-19 cases among residents and staff, focusing on infection prevention and control practices during the outbreak.
Complaint Details
The visit was complaint-related due to a COVID-19 outbreak among residents and staff. The investigation found multiple failures in infection prevention and control practices, including PPE availability and use, and isolation precaution management.
Findings
The facility failed to ensure appropriate personal protective equipment (PPE) was available and worn by staff according to CDC and Minnesota Department of Health guidelines during a COVID-19 outbreak. Deficiencies included lack of PPE on isolation carts, improper use of PPE by staff, failure to correctly identify residents requiring isolation precautions, and failure to remove isolation precautions timely.
Deficiencies (3)
Isolation carts outside multiple residents' rooms lacked gloves and hand sanitizer.
Staff observed not wearing required PPE including gowns, gloves, eye protection, and masks properly.
Failure to correctly identify residents requiring isolation precautions and failure to remove isolation precautions timely.
Report Facts
Residents affected: 141
Residents reviewed for isolation precautions: 3
Residents with PPE deficiencies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP-A | Nurse Practitioner | Observed leaving a room without full PPE and acknowledged the error. |
| NA-A | Nursing Assistant | Observed with mask under chin and acknowledged forgetting to pull it up. |
| HK-A | Housekeeper | Observed lacking gown and eye protection in isolation room and acknowledged the deficiency. |
| NA-C | Nursing Assistant | Observed lacking gown and protective eyewear and acknowledged not knowing resident identity or PPE requirements. |
| RA-A | Restorative Aide | Did not complete hand hygiene after resident contact and acknowledged the error. |
| IP | Infection Preventionist | Acknowledged lack of formal PPE education, audits, and responsibility for isolation cart maintenance. |
| DON | Director of Nursing | Interviewed regarding infection prevention monitoring and facility policies. |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 4
Date: Nov 16, 2023
Visit Reason
The inspection was conducted due to a COVID-19 outbreak investigation triggered by new cases among residents and staff, focusing on infection prevention and control practices.
Complaint Details
The visit was complaint-related due to a COVID-19 outbreak with multiple residents testing positive. The investigation found substantiated failures in infection prevention and control practices.
Findings
The facility failed to ensure appropriate personal protective equipment (PPE) was available and worn by staff according to CDC and Minnesota Department of Health guidelines during an outbreak. Deficiencies included lack of PPE on isolation carts, improper use of PPE by staff, and failure to correctly identify and manage isolation precautions for residents.
Deficiencies (4)
Isolation carts outside multiple COVID-19 positive residents' rooms lacked gloves and hand sanitizer.
Staff observed not wearing required PPE including gowns, gloves, eye protection, and masks properly in isolation areas.
Failure to correctly identify residents requiring isolation precautions and failure to remove isolation signs after isolation period ended.
Lack of formal education and audits on PPE use and infection prevention compliance.
Report Facts
Residents affected: 7
Total residents in building: 141
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP-A | Nurse Practitioner | Observed not wearing full PPE and acknowledged the risk of spreading COVID-19 |
| NA-A | Nursing Assistant | Observed with mask under chin during resident movement |
| HK-A | Housekeeper | Observed lacking gown and eye protection in isolation room and acknowledged PPE requirements |
| NA-C | Nursing Assistant | Observed lacking full PPE and unaware of resident identity in isolation room |
| RA-A | Restorative Aide | Did not perform hand hygiene after resident contact |
| IP | Infection Preventionist | Acknowledged lack of formal PPE education and audits, responsible for isolation carts and signage |
| DON | Director of Nursing | Interviewed about infection prevention monitoring and policies |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 30, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of verbal and physical abuse between two residents (R1 and R2) at the facility, including failure to assess and implement care plan interventions to prevent abuse and failure to timely report and investigate abuse incidents.
Complaint Details
The complaint involved verbal and physical abuse between residents R1 and R2, including racial slurs and physical altercations. The facility was aware of ongoing verbal abuse for months prior to the physical altercation on 10/16/23. Police were called multiple times. The facility failed to implement effective interventions or timely report the abuse to the state agency.
Findings
The facility failed to protect residents R1 and R2 from verbal and physical abuse, did not timely report abuse to the state agency within two hours, and failed to conduct thorough investigations including interviews, root cause analysis, and protective measures following incidents on 10/12/23 and 10/16/23. The facility allowed ongoing verbal abuse and physical altercations between R1 and R2 without effective interventions.
Deficiencies (3)
Failed to protect residents from verbal and physical abuse between R1 and R2, resulting in verbal and physical altercations.
Failed to timely report suspected abuse to the state agency within two hours after an allegation was made for residents R1 and R2.
Failed to complete thorough investigations and respond appropriately to alleged violations, including lack of interviews, root cause analysis, and protective measures following abuse incidents.
Report Facts
Incident date: Oct 12, 2023
Incident date: Oct 16, 2023
Incident time: 16:02
Incident time: 19:40
BIMS score: 14
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reviewed video footage of altercation, provided statements on incidents and facility response |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided statements on abuse history, interventions, and investigation process |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Provided statements on resident interactions and staff interventions |
| Health Unit Coordinator A | Health Unit Coordinator (HUC) | Witnessed altercation and described staff response |
| Clinical Support Specialist | Clinical Support Specialist | Provided statements on verbal abuse and reporting practices |
| Social Worker A | Social Worker | Discussed investigation roles and reporting |
| Social Worker B | Social Worker | Discussed investigation roles and reporting |
| Nursing Assistant A | Nursing Assistant (NAR) | Described resident interactions and staff interventions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 2, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide oxygen therapy according to physician orders for a resident (R1), resulting in harm.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to provide oxygen therapy as ordered, resulting in harm to resident R1. The resident experienced oxygen saturation of 65% and prolonged call light response times, leading to emergency services being called by the resident herself.
Findings
The facility failed to ensure continuous oxygen therapy for R1, who experienced oxygen saturation levels of 65% and had to call emergency services herself after prolonged unanswered call lights. Multiple interviews and record reviews showed conflicting accounts about R1's ability to manage oxygen equipment and call lights, with staff generally reporting R1 was compliant and unable to turn off oxygen, while the director of nursing claimed otherwise. The facility also had prolonged call light response times and documentation errors.
Deficiencies (1)
Failure to provide safe and appropriate respiratory care for a resident when needed, resulting in actual harm.
Report Facts
Call light prolonged response times: 15
Call light prolonged response times: 5
Call light prolonged response times: 2
Oxygen saturation: 65
Oxygen saturation: 93
Oxygen saturation: 92
Time call light was on: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Nurse for R1 on 9/25/23, described medication pass and lack of knowledge about R1's shortness of breath and 911 call |
| NA-A | Nursing Assistant | Provided care to R1, stated R1 was compliant with oxygen use and needed assistance for transfers |
| NA-B | Nursing Assistant | Reported R1 could not get up or turn oxygen on/off, and always turned call light off when responding |
| NA-C | Nursing Assistant | Worked with R1 daily, stated R1 was alert, cooperative with oxygen therapy, and never removed oxygen |
| NA-D | Nursing Assistant | Assisted R1 on 9/25/23, switched oxygen tubing but did not check concentrator power |
| NA-F | Nursing Assistant | Stated R1 always had oxygen on and never seen without oxygen |
| NA-G | Nursing Assistant | Reported R1 needed assistance to get up and never removed oxygen |
| NA-H | Nursing Assistant | Stated R1 always had oxygen on and allowed call light to be turned off |
| LPN-B | Licensed Practical Nurse | Described R1 as complicated case, anxious when not connected to oxygen, needing assistance to stand |
| NP | Nurse Practitioner | Discussed R1's decline, importance of oxygen, and oxygen saturation of 65% being incompatible with life |
| DON | Director of Nursing | Stated R1 turned off oxygen herself and fell, contradicted other staff and records |
| PO-A | Police Officer | Responded to R1's call, found oxygen concentrator off and R1 with 65% saturation |
| HS-B | Hospital Staff | Verified seeing R1 at emergency department on 9/25/23 with acute on chronic respiratory failure |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide necessary behavioral health care and services, specifically related to the management and monitoring of antipsychotic medication (Clozaril) for a resident with schizophrenia.
Complaint Details
The complaint investigation focused on the failure to provide necessary behavioral health care and services to a resident with schizophrenia, including failure to coordinate care with psychiatric providers, failure to monitor psychosis symptoms, and failure to obtain required monthly neutrophil blood tests before dispensing Clozaril. The resident missed nine doses of medication, leading to worsening symptoms and hospitalization. The complaint was substantiated with actual harm.
Findings
The facility failed to coordinate care with psychiatric providers, monitor symptoms of psychosis, and obtain required monthly neutrophil blood tests before dispensing Clozaril. This failure led to the resident missing nine doses of medication, resulting in worsening psychotic symptoms and hospitalization. The facility also lacked proper documentation and monitoring of target behaviors related to psychosis, and communication with the psychiatrist was inadequate.
Deficiencies (3)
Failure to coordinate care with psychiatric providers and monitor psychosis symptoms for resident on Clozaril.
Failure to obtain monthly neutrophil blood tests required for safe dispensing of Clozaril, resulting in missed medication doses.
Lack of documentation and monitoring of target behaviors related to worsening psychosis symptoms.
Report Facts
Missed medication doses: 9
Medication dosage: 200
Dates of medication refusal: 7
Neutrophil test dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MHCM-A | Mental Health Case Manager | Reported resident's psychiatric history and behaviors, alerted facility about refusals and worsening symptoms. |
| FNP-A | Facility Nurse Practitioner | Ordered monthly neutrophil blood tests and authorized hospital transfer for psychological evaluation. |
| LPN-A | Licensed Practical Nurse | Contacted medical providers regarding lab orders and notified staff of resident's refusals. |
| RN-B | Psychiatric Nurse | Reported missed Clozaril doses and coordinated medication titration after hospitalization. |
| P-A | Psychiatrist | Resident's long-time psychiatrist, provided medication orders and expressed concern over missed doses. |
| DON | Director of Nursing | Reviewed events related to missed medication doses and lab tests, provided explanations and oversight. |
| PH-A | Consultant Pharmacist | Recommended target behavior monitoring and explained medication dispensing requirements. |
| FMD-A | Facility Medical Director | Responsible for standard of care, explained medication monitoring requirements and target behaviors. |
| LSS-A | Laboratory Service Staff | Reviewed lab orders and refusals, explained lab procedures and communication with facility. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 18, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the improper use of a mechanical lift device for resident transfers, specifically the use of an EZ Stand lift instead of the required Arjo Master Lift for a resident unable to bear weight.
Complaint Details
The complaint investigation found that staff used the EZ Stand lift for resident R1 who required the Arjo lift, resulting in a fall or being lowered to the floor. Staff acknowledged improper lift use and failure to assess the resident prior to lifting from the floor. The complaint was substantiated with findings of minimal harm or potential for harm.
Findings
The facility failed to follow the care plan for one resident (R1) by using an EZ Stand lift instead of the required Arjo Master Lift, resulting in the resident falling or being lowered to the floor. Staff interviews confirmed improper lift use and lack of proper assessment before lifting the resident from the floor. Training on lift use was provided but not consistently followed.
Deficiencies (1)
Failure to ensure the care plan was followed to use the Arjo Master Lift instead of the EZ Stand for a resident unable to bear weight, leading to a fall.
Report Facts
Residents affected: 1
Staff interviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Interviewed regarding lift use and training after resident fall |
| NA-B | Nursing Assistant | Interviewed regarding lift use and resident fall incident |
| PTA-C | Physical Therapy Assistant | Interviewed about lift selection criteria and care plan adherence |
| LPN-A | Licensed Practical Nurse | Interviewed about the fall incident and care plan requirements |
| RN-A | Registered Nurse | Interviewed about staff compliance with lift use policies |
| Director of Nursing | Director of Nursing | Interviewed about staff training and policy adherence |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 10, 2023
Visit Reason
The inspection was conducted to investigate complaints related to pressure ulcer care, infection prevention and control practices, and vaccination policies at Providence Place nursing home.
Complaint Details
The complaint investigation focused on pressure ulcer care deficiencies for residents R93 and R2, infection prevention failures including staff not wearing masks during a COVID-19 outbreak, and failure to offer influenza vaccination to resident R2. The investigation included observations, interviews with nursing staff, nursing assistants, director of nursing, nurse practitioner, and infection preventionist, and review of medical records and facility policies.
Findings
The facility failed to provide appropriate pressure ulcer care for two residents, ensure staff compliance with infection prevention protocols including mask-wearing during a COVID-19 outbreak, and offer the influenza vaccine to one resident. Deficiencies included improper wound dressing management, failure to wear masks by staff in resident areas, and lack of documentation or follow-up for influenza vaccination.
Deficiencies (3)
Failed to ensure interventions were implemented to prevent, maintain or keep resident pressure injuries from worsening for 2 of 3 residents reviewed for pressure injuries.
Failed to ensure staff wore appropriate personal protective equipment (PPE) according to CDC and MDH guidelines during a facility outbreak with high county transmission rate.
Failed to ensure the influenza vaccine was offered to 1 of 5 residents reviewed for vaccinations.
Report Facts
Residents affected: 2
Residents affected: 157
Residents reviewed for vaccinations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-F | Licensed Practical Nurse | Named in findings related to failure to apply pressure relieving boots and improper wound dressing management for resident R93 |
| NA-L | Nursing Assistant | Named in findings related to failure to notify nurse when wound dressing came off for resident R93 |
| RN-C | Registered Nurse | Provided statements regarding wound care rounds and dressing documentation |
| DON | Director of Nursing | Provided statements regarding wound care documentation and mask-wearing policy |
| NP | Nurse Practitioner | Provided statements regarding wound care expectations and documentation |
| NA-K | Nursing Assistant | Observed and interviewed regarding mask-wearing during resident care |
| RN-B | Registered Nurse | Observed entering nurse's station without mask and interviewed about mask policy |
| IP | Infection Preventionist | Provided statements regarding COVID-19 outbreak, mask policy, and vaccination follow-up |
| RN-E | Registered Nurse | Tested positive for COVID-19 and was source of outbreak investigation |
Inspection Report
Routine
Deficiencies: 9
Date: Feb 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, safety, care, medication administration, nutrition, hospice services, and smoking policies.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity regarding urinary catheter privacy, inadequate accessibility of call lights, unsanitary conditions of wheelchairs and feeding equipment, failure to provide routine toileting and nail care, inadequate resident-centered care for legally blind residents, unsafe smoking practices, medication administration errors, nutritional inadequacies, and failure to provide hospice choice options to residents and their representatives.
Deficiencies (9)
Failure to ensure dignity was maintained for residents with urinary catheters by not covering catheter bags as required.
Failure to ensure call lights were accessible to residents who needed them, leaving residents unsafe.
Failure to maintain a sanitary and homelike environment including unclean wheelchairs and feeding tube equipment.
Failure to provide routine toileting/incontinence care and nail care as required for dependent residents.
Failure to provide resident-centered care and assistance to legally blind residents to maintain their highest practicable well-being.
Failure to comprehensively assess, monitor, and re-evaluate residents for safe smoking practices and storage of smoking materials.
Significant medication administration error when one resident was offered another resident's medications.
Failure to ensure menus and individual resident food plans met nutritional needs and preferences.
Failure to provide residents and their representatives with a complete list of hospice providers to allow choice when the facility ended contract with current hospice provider.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Mentioned in relation to catheter dignity and nail care deficiencies |
| RN-C | Registered Nurse | Mentioned in relation to call light accessibility and medication administration error |
| TMA-B | Trained Medical Assistant | Involved in medication administration error |
| LPN-D | Licensed Practical Nurse | Mentioned in relation to smoking assessment and monitoring |
| NA-J | Nursing Assistant | Mentioned in relation to resident assistance and mail handling |
| SW-B | Social Worker | Involved in hospice provider change communication |
| DON | Director of Nursing | Provided statements on multiple deficiencies including dignity, smoking, medication, hospice |
| RD | Registered Dietitian | Mentioned in relation to nutritional assessment and meal adequacy |
| NA-C | Nursing Assistant | Mentioned in relation to meal service and menu knowledge |
| NA-D | Nursing Assistant | Mentioned in relation to resident food service |
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