Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Place during CMS and state inspections, most recent first.
Staff did not test dishwashing sanitization chemicals due to lack of test strips and failed to label and date opened food items, as evidenced by an open, undated gallon of milk found in the refrigerator. Dietary staff confirmed the absence of required testing and labeling practices.
Hazardous cleaning chemicals were left unsecured and accessible to cognitively impaired, mobile residents. A resident with severe cognitive impairment experienced a non-injury fall when staff failed to lock wheelchair brakes during a transfer. Another resident with a history of falls was observed with their call light and personal items out of reach, contrary to care plan interventions. Staff interviews confirmed that these actions did not follow facility policy or care plans.
A medication storage room containing stock medications and enteral feeding solutions was found unlocked during a walkthrough. An LN confirmed the door should always be locked, but reported issues with the doorknob sticking. Facility policy requires all medications to be secured in locked storage.
Surveyors identified multiple infection control deficiencies, including trash left on a PPE cart, a clean linen closet propped open, lack of accessible hand hygiene supplies in the laundry area, and missing gloves in the dirty laundry area. Staff interviews confirmed these practices were inconsistent with facility policy and that all staff are responsible for maintaining proper infection control.
A resident with significant physical and cognitive impairments was not provided with required adaptive utensils and a two-handled cup during meals, despite documented care plans and orders. Staff served meals with standard utensils, and the resident was observed struggling to eat while wearing wrist orthoses. Staff interviews confirmed expectations to follow care plans, but the adaptive equipment was not provided as required.
A resident with severe cognitive and physical impairments, dependent on staff for personal care, was repeatedly observed with dirty fingernails containing a dark substance. Despite facility policy and staff interviews confirming responsibility for nail care during bathing and showers, staff did not consistently ensure the resident's fingernails were clean.
A resident with end-stage renal disease and multiple comorbidities did not have consistent pre- and post-dialysis communication and assessment documentation as required by facility policy. Nursing and administrative staff confirmed that dialysis communication forms were often missing from the resident's record, and procedures to obtain or return these forms from the dialysis center were not reliably followed, resulting in incomplete documentation of dialysis care.
A resident with severe cognitive impairment, decreased mobility, and multiple diagnoses was provided with bilateral bed rails without documented evidence that alternatives had been tried and failed, as required by facility policy. The assessment also lacked information on drug classifications that could increase entrapment risk, resulting in a deficiency related to bed rail use.
A resident with severe cognitive impairment and multiple diagnoses was prescribed Dulcolax DR without 'do not crush' instructions, despite a consultant pharmacist's recommendation to add this directive. The facility did not act on the pharmacist's recommendation as required by policy, and the medication administration record lacked the necessary instruction.
The facility did not accurately document and submit weekend staffing coverage hours in its Payroll Based Journaling (PBJ) reports to CMS, despite using agency staff and having no gaps in internal schedules or time sheets. This discrepancy was identified when the facility's PBJ data triggered for excessively low weekend staffing, and an administrative nurse acknowledged that agency staff hours may not have been properly reported.
Failure to Test Dishwashing Sanitizer and Label Opened Food Items
Penalty
Summary
Staff failed to properly test dishwashing sanitization chemicals and did not ensure that opened food items were labeled and dated. During a kitchen and dining area tour, surveyors observed an open, undated gallon of milk in the refrigerator. Dietary staff confirmed that dishes were being washed by hand in a three-sink system using hot water and chemicals, but there were no test strips available to verify the effectiveness of the sanitization process, nor was there a log to review. Staff also acknowledged that all opened food items should be labeled and dated, but this was not done for the milk observed during the inspection.
Failure to Secure Hazardous Chemicals and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to secure hazardous cleaning chemicals in a locked area, leaving disinfectant bleach wipes and a Clorox spray bottle accessible in an unsecured cabinet on the 300 Hall. These chemicals were labeled with warnings indicating they were hazardous to humans and should be kept out of reach of children. Eight cognitively impaired, independently mobile residents had access to this area. Staff interviews confirmed that facility policy required chemicals to be locked up, but this was not followed at the time of observation. A resident with severe cognitive impairment, chronic kidney disease, emphysema, muscle weakness, and a history of falls experienced a non-injury fall during a transfer. Staff failed to lock the brakes on the resident's wheelchair before attempting the transfer, causing the wheelchair to move and resulting in the resident being assisted to the ground. The care plan for this resident required staff to lock wheelchair brakes before transfers, and staff had been educated on this procedure, but it was not followed during the incident. Another resident with diabetes, renal failure, cognitive impairment, and a history of falls was observed sitting in a recliner with their call light and personal items out of reach, contrary to the care plan interventions. The care plan specified that the call light and needed items should be within reach and that staff should encourage the resident to call for assistance. Staff interviews confirmed that it was everyone's responsibility to ensure fall interventions were in place as care planned, but these interventions were not implemented at the time of observation.
Medication Storage Room Found Unsecured
Penalty
Summary
A deficiency was identified when one of two medication storage rooms, specifically the 100 Hall Team Office medication storage room, was found unsecured during an initial facility walkthrough. The room contained shelves of stock medication, enteral feeding solutions, and medical supplies. A licensed nurse confirmed that the door should be locked at all times due to the presence of medications, but noted that the doorknob sometimes stuck and did not close properly. Facility staff were expected to ensure the room remained locked when exiting, as per the facility's Medication Storage policy, which requires all medication to be secured in a locked manner.
Infection Control Lapses in Trash Disposal, Linen Storage, and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by several observed deficiencies. During an initial walkthrough, a clear bag of trash was found left on top of a PPE cart in the 300 halls, and a clean linen closet was observed propped open in the same area. In the laundry room, there was no visible handwashing sink or PPE available. Staff reported that handwashing required retrieving soap from the dirty laundry area, using a laundry soaking sink, and then returning to the dirty area to dry hands, indicating a lack of accessible hand hygiene supplies. Additionally, gloves were not available in the dirty laundry area, and staff were not consistently aware of the location of the handwashing sink in the laundry room. Interviews with staff confirmed that trash should not be left on PPE carts, linen closets should not be propped open, and it is the responsibility of all staff to ensure proper disposal of trash and maintenance of infection control standards. The facility's infection control policy requires the provision of necessary supplies and oversight to ensure hand hygiene, but observations and staff statements indicated lapses in these practices. These deficiencies were identified among a census of 35 residents, including seven on Enhanced Barrier Precautions.
Failure to Provide Required Adaptive Utensils During Meals
Penalty
Summary
The facility failed to provide a resident with the required adaptive utensils during mealtimes, despite clear documentation in the care plan and physician orders indicating the need for built-up silverware and a two-handled cup to support self-feeding. The resident, who had diagnoses including left-sided hemiplegia, cerebral infarction, dysphagia, muscle weakness, cognitive communication disorder, reduced mobility, and muscle contractures, was observed eating multiple meals with standard utensils and a regular cup, while wearing wrist orthoses. Staff did not offer the adaptive equipment during these meals, and the resident was noted to have difficulty handling the utensils. Interviews with staff confirmed that they were expected to review care plans and dietary requirements before serving meals, and that information about special utensils was accessible to all staff. The facility's policy required screening and provision of adaptive equipment to improve resident independence and quality of care. Despite these expectations and policies, the resident did not receive the necessary adaptive utensils during observed meals, constituting a failure to implement the care plan and physician orders.
Failure to Maintain Resident Nail Hygiene During ADL Assistance
Penalty
Summary
Staff failed to provide adequate assistance with activities of daily living (ADL) for a resident who was dependent on staff for personal care due to multiple diagnoses, including dementia, hemiparesis following a stroke, Parkinson's disease, and muscle weakness. The resident's medical record and care plan documented severe cognitive impairment and a need for staff assistance with bathing, toileting, oral hygiene, and dressing. Despite these needs, observations on multiple occasions revealed that the resident's fingernails had a dark brown substance underneath, indicating they were not being kept clean. Interviews with facility staff confirmed that CNAs are responsible for cleaning residents' fingernails during showers or bed baths, and that all staff are expected to monitor nail cleanliness. The facility's policy emphasized promoting cleanliness during bathing and showering. However, the repeated observations of dirty fingernails demonstrated that staff did not consistently ensure the resident's fingernails were clean, resulting in a failure to meet the resident's ADL needs as outlined in their care plan.
Failure to Ensure Consistent Pre- and Post-Dialysis Communication and Assessment
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition through pre- and post-dialysis communication prior to and after hemodialysis sessions. The resident in question had multiple complex medical diagnoses, including end-stage renal disease requiring hemodialysis, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, and a recent cervical spine fracture requiring a neck collar. The care plan required daily assessment of the arteriovenous (AV) fistula and completion of dialysis communication forms before and after each dialysis session. However, review of the electronic medical record revealed missing documentation of pre- and post-dialysis assessments and communication forms on several specified dates. Interviews with nursing staff and administration confirmed that the process for handling dialysis communication sheets was not consistently followed. Staff reported that completed forms were to be placed in a binder and scanned into the resident's chart, and if missing, the dialysis center was to be contacted for a report. Administrative staff acknowledged ongoing issues with obtaining completed communication sheets from the dialysis center and had attempted to address this by sending the forms in a binder. Despite these procedures, the required documentation was not consistently present, resulting in a failure to ensure proper communication and assessment related to the resident's dialysis care.
Failure to Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident had a documented risk assessment that included alternatives that had been tried and failed prior to the use of bed rails. The resident in question had diagnoses of major depressive disorder, Alzheimer's disease, cerebrovascular accident, and was noted to have severely impaired cognition, decreased mobility, blindness, and dementia. The care plan indicated the use of bilateral upper quarter bedrails to assist with bed mobility, and the facility's assessment documented that the resident's representative had given verbal consent for the side rails. However, the assessment did not include documentation of alternatives to bed rails that had been attempted and found ineffective, nor did it address drug classifications that could increase the risk of entrapment. Observations confirmed that the resident was using bilateral upper bed rails, and staff interviews revealed that side rail assessments were conducted at admission, quarterly, annually, and with significant changes. Staff also stated that the interdisciplinary team reviewed factors such as medication, mobility, mental status, safety awareness, and history of falls when making decisions about side rail use. Despite these procedures, the facility's policy required that appropriate alternatives be attempted before installing bed rails, and this was not documented in the resident's assessment, resulting in a deficiency.
Failure to Implement Pharmacist's Medication Safety Recommendation
Penalty
Summary
The facility failed to act upon the Consultant Pharmacist's recommendation to add 'do not crush' instructions to a resident's Dulcolax delayed release (DR) medication order. The resident in question had diagnoses of major depressive disorder, Alzheimer's disease, and a history of cerebrovascular accident, with severely impaired cognition and significant assistance required for activities of daily living. The resident's care area assessment indicated a risk of adverse side effects from medications, and the care plan directed nursing staff to administer medications as ordered by the physician. However, the medication order for Dulcolax DR did not include 'do not crush' instructions, despite the pharmacist's recommendation documented in the monthly medication review. Review of the resident's medication administration record for the relevant month confirmed the absence of the 'do not crush' directive for Dulcolax. Interviews with administrative nursing staff revealed an expectation that pharmacy recommendations would be reviewed and acted upon within seven days, but this was not done in this case. The facility's policy required that drug regimen reviews be conducted monthly by a licensed pharmacist, with any identified irregularities reported to the attending physician, medical director, and director of nursing services for action. The failure to implement the pharmacist's recommendation resulted in a deficiency related to the management of the resident's medication regimen.
Failure to Accurately Report Weekend Staffing in PBJ Data
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ) by not properly documenting weekend staffing coverage hours. During the review period, the facility reported a census of 36 residents and a sample of 12 residents was included. Although the facility's working schedules, time sheets, and posted staffing hours showed no gaps or loss of hours, the submitted PBJ data triggered for excessively low weekend staffing for the first quarter of the fiscal year. An administrative nurse confirmed that agency staff were used during the period in question, but their hours may not have been appropriately documented in the PBJ reporting. The facility's policy required accurate electronic reporting of staffing and census information to CMS and mandated that this information be made available to residents, family members, and the public within 24 hours of a request.
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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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| The Healthcare Resort Of Kansas City | 0.1 mi | ★★★★★ | 32 | 0 |
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| Kaw River Care And Rehab | 5.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.