Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Health Care Center during CMS and state inspections, most recent first.
The facility failed to initiate timely treatment orders and wound care for pressure ulcers and skin damage identified at or shortly after admission for three residents. One resident was admitted with a documented buttock/coccyx wound and hospital instructions for Mepilex and barrier cream, but the admission skin assessment omitted this wound and the TAR showed no treatment orders for several days, during which in-house moisture-associated damage and later a stage 3 pressure ulcer developed. Another resident had pressure ulcers on both buttocks noted in nursing documentation and an unhealed pressure ulcer on the MDS, yet there was no detailed wound assessment or treatment orders on the TAR until days later, after which a wound NP documented two stage 3 buttock ulcers. A third resident was admitted with moisture-associated buttock damage and a sacral deep tissue injury present on admission, but no physician’s treatment order appeared on the TAR until days after these findings. The DON acknowledged that treatments were not initiated at admission and that facility policy required notifying the physician and obtaining orders when new skin issues were identified.
A resident admitted with a stage 1 coccyx pressure ulcer did not receive a timely wound assessment or treatment orders, resulting in the ulcer worsening to stage 3 before intervention. Staff interviews and record review confirmed that required assessments and physician notifications were not completed as per facility policy.
Surveyors found that medications in two storage rooms were not properly labeled or disposed of according to policy. An opened vial of Aplisol was undated, and a bottle of compounded mouthwash for a resident was stored past its expiration date. Nursing staff confirmed the labeling and disposal requirements were not followed.
A resident with severe cognitive impairment experienced a fall with a hip fracture, but staff did not promptly notify the physician or act on x-ray results, resulting in delayed hospital transfer. In a separate case, a topical medication order for another resident was not discontinued or clarified after 60 days, despite pharmacy recommendations, due to lack of documentation and follow-up by nursing staff.
A resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls, including one resulting in a hip fracture. After each fall, documentation did not show that a root cause analysis was completed or that new, resident-specific interventions were implemented to prevent further incidents. The care plan remained generic and was not updated to address the specific reasons for the falls, and staff confirmed that required post-fall procedures were not followed.
A resident with an indwelling urinary catheter was observed multiple times with the catheter drainage bag touching or dragging on the floor while in a wheelchair. Nursing staff confirmed that the bag should not touch the floor, and facility policy required proper positioning of catheter bags and tubing to prevent floor contact. These observations demonstrated a failure to follow established catheter care protocols.
Two residents requiring respiratory care did not receive safe and appropriate respiratory equipment management, as staff failed to properly clean, dry, and store nebulizer and suction equipment according to facility policy. Observations showed used equipment was returned to storage bags while still wet or visibly soiled, and suction tubing was stored with other respiratory items, despite staff acknowledging the need for proper cleaning and separation.
Failure to Initiate Timely Pressure Ulcer Treatments on Admission
Penalty
Summary
The deficiency involves the facility’s failure to initiate and provide timely pressure ulcer and wound treatments for multiple residents upon admission or when wounds were first identified. For Resident B, pre-admission screening and hospital discharge instructions documented a wound to the right buttock/coccyx with specific orders for Mepilex and barrier cream. However, the admission skin assessment did not document a buttock or coccyx wound, and the Treatment Administration Record (TAR) for November lacked evidence of any physician’s treatment orders for the buttocks or coccyx prior to several days after admission. Subsequent notes showed moisture-associated skin damage to the right buttock identified as acquired in-house and, later, a stage 3 pressure ulcer to the right inner buttock, with treatment orders not obtained until after these findings. For Resident C, the admission MDS indicated an unhealed pressure ulcer, and nursing notes documented pressure ulcers on each buttock with physician notification. The resident was sent to the ER and later returned, with a skin check note indicating a buttock wound but lacking a detailed wound assessment or measurements. A physician’s order for cleansing and applying Medihoney with bordered gauze to bilateral buttock wounds was not obtained until days after the wounds were documented, and the December TAR lacked documentation of any treatment orders for these pressure ulcers prior to that date. A wound NP later documented two stage 3 pressure ulcers, one on each buttock, and recommended specific topical treatments. For Resident D, a skin check documented moisture-associated skin damage to the buttocks at admission, and a wound NP note the following day identified a deep tissue injury to the sacrum that was present on admission. Despite this, the TAR for January showed no physician’s order for treatment of the sacral wound until a later date, when an order was finally written for cleansing, Triad cream, antifungal powder, and leaving the area open to air twice daily. In an interview, the DON confirmed she could not find documentation that wound treatments were initiated at the time of admission for these residents and stated that nurses should have followed hospital discharge instructions, notified the wound nurse, and obtained treatment orders at admission or when wounds were found. The facility’s policy required nurses to notify the attending physician and obtain treatment orders when new skin abnormalities were noted, but this was not done in these cases.
Failure to Assess and Treat Pressure Ulcer on Admission
Penalty
Summary
Staff failed to assess and implement treatment for a pressure ulcer in a resident who was admitted with a stage 1 wound to the coccyx, as documented in the hospital discharge information. Upon admission, there was no evidence in the medical record that the wound was assessed or that a physician order for treatment was obtained. The first documented wound assessment and treatment order occurred seven days after admission, by which time the wound had progressed to a stage 3 pressure ulcer. The care plan initially addressed only the potential for pressure wounds and did not include interventions for an actual wound. Interviews with nursing staff and the DON confirmed that the resident's wound was not assessed at admission, and that treatment orders were not obtained until a week later. Staff indicated that if a resident refused assessment, they would continue to attempt assessment and notify the physician, but there was no documentation of these actions. The facility's policy required a skin assessment and Braden Scale on admission, as well as documentation of any skin abnormalities and physician notification, but these steps were not followed in this case.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors observed that the facility failed to properly label and dispose of medications in accordance with professional standards and facility policy. In the north hall medication storage room, an opened multi-use vial of Aplisol was found in the refrigerator without a date indicating when it was opened. A registered nurse interviewed at the time was not aware of the specific duration the Aplisol remained usable after opening, but acknowledged that it should have been dated. In the south hall medication storage room, an opened bottle of Mary's Magic Mouthwash, labeled for a specific resident, was found in the refrigerator past its expiration date. The assistant director of nursing confirmed that the mouthwash should have been discarded two days prior and that Aplisol vials are only good for 30 days after opening and should be dated accordingly. Facility policy documents provided by the administrator confirmed that open vials of Aplisol should be discarded after 30 days and that no drugs or biologicals should be stored beyond their manufacturer’s or facility-established expiration date. The findings indicate that the facility did not adhere to its own policies regarding medication labeling and disposal, resulting in expired and improperly labeled medications being stored in both medication storage rooms.
Delayed Treatment After Fall and Failure to Discontinue Medication Order
Penalty
Summary
The facility failed to prevent a delay in treatment after a fall resulting in a fracture for one resident. After the resident, who had severe cognitive impairment, fell and complained of hip and knee pain, staff assessed her but did not immediately notify the physician or document timely communication regarding her pain and the fall. The resident was moved to bed despite her complaints of pain, and there was a lack of clear documentation about when the physician was notified. An x-ray was ordered later, revealing an acute femur fracture, but the results were not promptly acted upon, and the resident was not sent to the hospital until the following day. Facility policy required that suspected bone or joint injuries not be moved until seen by a physician or transported, and that abnormal diagnostic results be promptly communicated to the physician, which was not followed in this case. In a separate incident, the facility failed to ensure a treatment order for a topical cream was discontinued or clarified after 60 days for another resident. The order for Ammonium Lactate Cream was written without a specific stop date and remained active beyond the intended duration. The pharmacy recommended discontinuation after 60 days, but there was no documentation that the order was discontinued or clarified. The DON indicated the pharmacy recommendation should have been addressed by nursing staff, and the pharmacist should have included a stop date when the order was initiated. Both deficiencies were supported by interviews and record reviews, which revealed lapses in communication, documentation, and adherence to facility policies regarding physician notification, post-fall assessment, and medication order management. These failures resulted in delays in appropriate treatment and care according to physician orders and resident needs.
Failure to Complete Root Cause Analysis and Implement Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that a root cause analysis was completed and appropriate interventions were implemented following multiple falls experienced by a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including a left femur fracture, was found on the floor on several occasions, including an incident where she fractured her hip. Documentation revealed that after these falls, there was a lack of immediate or resident-specific interventions to prevent further incidents, and the care plan was not updated to reflect new strategies addressing the causes of the falls. Progress notes and post-fall evaluations indicated that the resident was found on the floor multiple times, often after attempting to ambulate without her walker or while trying to use the bathroom. Despite these events, the records lacked documentation of why the resident was not using her walker and did not include new interventions to address this behavior. The care plan interventions remained generic and were not revised to address the specific circumstances or root causes of the resident's repeated falls. Interviews with facility staff, including the Assistant Director of Nursing, confirmed that a root cause analysis and new interventions should have been completed and documented after each fall, but this was not done. The facility was unable to provide evidence of interventions implemented after the falls, and interdisciplinary team notes were missing for these incidents. The lack of timely and individualized interventions contributed to the deficiency cited in the report.
Catheter Bag Found Touching Floor During Resident Care
Penalty
Summary
A resident with a history of urinary retention, malignant neoplasm of the prostate, and benign prostatic hyperplasia was observed with an indwelling urinary catheter attached to a drainage bag. On multiple occasions, the catheter bag was seen touching or dragging on the floor while the resident was seated in a wheelchair and propelling himself. The resident was cognitively intact and aware of having a catheter, though unsure of the specific reason for its use. Interviews with nursing staff confirmed that the catheter bag should not touch the floor, and facility policy also required that urinary drainage bags and tubing be positioned to prevent contact with the floor. Despite these standards, the observations showed that the catheter bag was not properly positioned, resulting in noncompliance with facility policy and accepted standards of catheter care.
Failure to Properly Clean and Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of respiratory equipment for two residents who required respiratory care. In one instance, a registered nurse administered a breathing treatment to a resident with COPD and asthma, then disposed of the remaining medication and returned the used respiratory mask and tubing to a clear plastic bag without evidence of proper rinsing or drying. The resident's care plan and physician's orders indicated the need for regular respiratory therapy, but the observed practice did not align with the facility's policy, which requires rinsing and drying of equipment before storage. For another resident with acute and chronic respiratory failure, traumatic brain injury, and quadriplegia, multiple observations revealed that nebulizer equipment was stored wet inside a clear bag next to the bed, and the suction tubing was visibly soiled with green and white debris. The suction canister was half full of green liquid, and the suction tubing was stored together with the nebulizer set, contrary to the facility's policy that requires separate storage and cleaning. Interviews with nursing staff confirmed that equipment was sometimes rinsed and placed in storage bags while still wet, and the DON acknowledged that equipment should be clean and dry before storage. The facility's own policies for nebulizer and suction equipment require thorough washing, rinsing, air drying, and separate storage of clean equipment. However, direct observations and staff interviews demonstrated that these procedures were not consistently followed, resulting in improper cleaning and storage of respiratory equipment for residents who required ongoing respiratory therapy and suctioning.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near St Mary Of The Woods
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Terre Haute | 3.6 mi | ★★★★★ | 9 | 0 |
| Harrison's Crossing Health Campus | 3.8 mi | ★★★★★ | 2 | 0 |
| Signature Healthcare Of Terre Haute | 5.8 mi | ★★★★★ | 19 | 0 |
| Westridge Health Care Center | 6.1 mi | ★★★★★ | 10 | 0 |
| Majestic Care Of Deming Park | 6.5 mi | ★★★★★ | 4 | 2 |
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