Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Care Center during CMS and state inspections, most recent first.
A resident with PAD and prior left leg vascular intervention developed ongoing left leg pain, tingling, numbness, and mottled discoloration while receiving Eliquis. Staff documented repeated pain complaints and gave PRN oxycodone and increased gabapentin, but missed some anticoagulant doses, did not document vascular assessments, did not complete skin assessments when symptoms worsened, and did not notify the vascular surgeon about the change in condition or the lowered Eliquis dose. When the resident was finally seen by the vascular surgeon, the left leg had absent distal pulses and absent sensation, and the resident required urgent hospital admission for IV heparin and an endovascular procedure.
A resident with CVA, PAD, and prior left leg vascular intervention missed multiple ordered Eliquis doses because the medication was unavailable, on order, or not yet delivered, and staff were unaware it was available in the contingency box. The facility physician reduced the Eliquis dose without consulting the vascular surgeon, and the vascular surgeon’s office was not informed of the change. The resident later presented with weeks of left leg pain, tingling, and mottled discoloration, and was found to have a distal SFA occlusion requiring urgent hospital admission and heparin therapy.
Failure to use therapy-ordered positioning equipment for a resident who needed help maintaining alignment in bed. The resident had morbid obesity, DM, bladder CA, and CKD, and PT documented dependence for repositioning, a tendency to lean left, and staff education on using a wedge cushion and bolster for supine positioning. During survey, the resident said staff did not place the equipment in the bed unless asked, and observations showed the wedge and bolster stored elsewhere while the resident was in bed; a CNA confirmed the equipment was not being used as intended.
A resident with OSA, morbid obesity, DM, bladder cancer, and CKD was ordered CPAP assistance at bedtime, but the care plan was silent and the TAR lacked documentation of the ordered treatment. The resident reported staff did not consistently apply the CPAP, said she could not do it herself, and stated she felt lethargic and tired during the day. An observation found the CPAP on the nightstand instead of on the resident, and a CNA confirmed night staff failed to assist with CPAP application.
Incomplete Investigation of Resident Abuse Allegation: A resident with cerebral infarction, restless leg syndrome, major depressive disorder, and moderately impaired cognition alleged that a CNA was rough during care and spoke unkindly. The facility’s abuse investigation included only one LSW statement, with no statement from the resident or CNA, no physical assessment, no interviews of like residents, and no suspension of the CNA while the allegation was reviewed; the DON and Administrator later verified there was no further investigatory documentation.
Missing Documentation for Incontinence Care: Three residents with significant toileting needs and bowel/bladder incontinence had multiple gaps in incontinence care documentation across several months. One resident was cognitively intact, one had moderate cognitive impairment, and one had severe cognitive impairment; all required staff assistance with toileting, and the Administrator confirmed the care tasks could not be verified because they were not documented.
A resident with diabetes, osteomyelitis, COPD, cognitive impairment, and unhealed pressure ulcers had detailed provider orders and a care plan for daily right ischial wound care and sacral NPWT (wound-vac), with wet-to-dry dressings only as an alternative if NPWT could not be maintained. Review of treatment records showed multiple missed wound treatments and wound-vac dressing changes, confirmed by nursing staff as not completed. During observation, the wound-vac machine was found unused in a chair, and the resident’s sacral area was covered with an ABD pad and gauze instead of the ordered NPWT dressing, while the resident reported the wound-vac should have been in place. An LPN stated she had last applied the wound-vac several days earlier, and an NP acknowledged concerns that some wound care had not been completed, despite no reports of wound-vac equipment malfunction, contrary to the facility’s pressure injury management policy.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy by not wearing required PPE during wound care for a cognitively impaired resident with unhealed pressure ulcers, a suprapubic catheter, and multiple comorbidities including DM, osteomyelitis, and COPD. EBP signage on the room door directed staff to wear a gown and gloves for high-contact care such as wound and catheter care, and a PPE cart was available. An LPN performed sacral wound care and a CNA assisted with positioning, but both wore only gloves and did not don gowns, despite the resident being on EBP for wounds and a urinary catheter. The LPN later confirmed awareness that the resident was on EBP and acknowledged that appropriate PPE had not been used, contrary to the facility’s written EBP policy.
A resident with severe cognitive impairment was alleged to have been inappropriately touched by an LPN during medication administration. The LPN continued to work on the same unit with other residents while the abuse investigation was ongoing, contrary to facility policy requiring protective measures during such investigations.
A resident with severe cognitive impairment was involved in an alleged inappropriate touching incident by a male LPN during medication administration. Although the incident was reported to the Administrator and the resident's POA, there was no documentation in the medical record that the physician was notified, as required by facility policy. The LPN involved was also unsure of the need to notify the physician.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident and their family were not informed about the discontinuation of a seizure medication, Phenytoin Sodium (Dilantin), despite the facility's policy requiring notification for such changes. The resident, who was cognitively intact, had a complex medical history. Interviews confirmed that neither the resident nor the family was notified, violating the facility's notification policy.
The facility failed to follow infection control policies for urinary catheter bags for two residents. A resident with a BIMS score of 14 had his urine collection bag on the floor, confirmed by an RN. Another resident with a BIMS score of 03 had his bag dragging on the ground while being pushed in a wheelchair, verified by an LPN. The facility's policy requires proper catheter care, which was not adhered to.
Failure to Assess and Report Worsening Limb Ischemia
Penalty
Summary
The facility failed to accurately and timely assess an acute change in condition, failed to collaborate with the vascular surgeon, and failed to timely recognize significant changes in condition for a post-surgical resident with peripheral artery disease. The resident had a history of left lower extremity angiogram, thrombectomy, stenting, and balloon angioplasty, and had been ordered Eliquis twice daily after the procedure. The record showed repeated complaints of left lower leg pain, burning pain, severe pain, tingling, numbness, and discoloration over several weeks, with multiple doses of oxycodone given and gabapentin increased, while the resident also missed some Eliquis doses because the medication was unavailable. The resident’s condition continued to be documented as pain in the left lower leg, including tenderness from the knee to the ankle and red discoloration, but the facility physician treated the symptoms as possible neurogenic, sciatic, or cellulitis-related pain and ordered venous dopplers, which were negative. The record did not show that the vascular surgeon was consulted when the Eliquis dose was lowered, and the vascular surgeon’s office later reported it had not received notification from the facility about the resident’s ongoing leg pain or missed anticoagulant doses. The DON stated staff completed vascular assessments but failed to document them, and also verified the care plan was incomplete and that the facility failed to recognize the resident’s change in condition and complete skin assessments when the resident complained of left lower leg pain. When the resident was seen by the vascular surgeon, the left lower extremity was found to have palpable femoral pulses bilaterally but no appreciable distal flow, no distal pulses, absent sensation over the left foot, and clammy mottled skin. The resident was diagnosed with a distal superficial femoral artery occlusion and required urgent hospital admission for IV heparin therapy, followed by an endovascular intervention to restore perfusion to the left lower extremity. The resident and family reported that the pain and discoloration had been ongoing for weeks before the office visit, and the surgeon’s nurse stated the surgeon was upset that the facility had not notified the office of the leg pain and missed anticoagulant doses.
Missed Anticoagulant Doses and Failure to Coordinate Vascular Care
Penalty
Summary
The facility failed to ensure that Eliquis was administered as ordered for a resident with a history of CVA, PAD, anemia, and hypertension after a January hospitalization for left lower extremity angiogram, mechanical thrombectomy, stenting of the SFA and popliteal arteries, and balloon angioplasty. The resident had an order for Eliquis 5 mg twice daily, which was later reduced to 2.5 mg twice daily by the facility physician based on a pharmacy recommendation due to an elevated creatinine level. The record states the vascular surgeon was not consulted about the dose reduction, and the resident’s care plan and MDS did not identify anticoagulant therapy. The MAR and progress notes showed missed Eliquis doses on multiple occasions because the medication was unavailable, on order, or not yet delivered. Specifically, the resident did not receive the evening dose on 05/04/26, both doses on 05/28/26, the evening dose on 05/29/26, the evening dose on 05/31/26, and the evening dose on 06/02/26. Nursing documentation also noted that on 06/02/26 the resident had severe left lower leg pain and refused ace wraps. Staff interviews confirmed that Eliquis was available in the contingency box, but nurses caring for the resident were unaware of that fact. At the vascular surgeon appointment on 06/04/26, the resident and family reported about five weeks of left lower extremity pain, tingling, and mottled discoloration. The vascular surgeon found palpable femoral pulses bilaterally but no appreciable distal flow in the left lower extremity, no distal pulses, absent sensation over the left foot, preserved proximal sensation, and clammy mottled skin. The resident was diagnosed with a distal superficial femoral artery occlusion and required urgent hospital admission. The hospital record states the resident was admitted directly from the vascular surgeon’s office with a cold left leg and edema, had been on Eliquis, and was started on a high-intensity heparin infusion with surgery planned for the next day. Interviews with the vascular surgeon’s office, the DON, the facility physician, and the resident’s niece confirmed the missed anticoagulant doses and that the vascular surgeon’s office had not been informed of the Eliquis dose reduction.
Failure to Use Ordered Positioning Equipment
Penalty
Summary
The facility failed to ensure therapy-ordered positioning equipment was used for a resident who needed assistance maintaining body alignment in bed. Resident #39 was admitted with diagnoses including morbid obesity, diabetes mellitus, bladder cancer, and chronic kidney disease. The resident’s quarterly MDS showed mild cognitive decline and substantial assistance was required for all ADLs except eating. The resident’s care plan was silent regarding positioning, and there was no physician order specifically addressing positioning equipment. Physical therapy documentation stated the resident was dependent for repositioning to maintain straight alignment in bed and that staff were educated on bolster placement to keep the resident centered and prevent a left lateral lean. A later PT note documented that the resident was provided a different wedge cushion due to discomfort with the prior one and that staff training was provided on supine positioning and use of the wedge cushion. However, during the survey the resident stated staff failed to place the wedge or bolster in the bed unless she asked for it, and observations showed the wedge cushion in the wheelchair and the bolster in the recliner while the resident was in bed. A CNA confirmed the equipment was not in the bed and stated it should be used when the resident was in bed.
Failure to Assist with Ordered CPAP Use
Penalty
Summary
The facility failed to ensure required respiratory treatment was implemented as ordered for a resident with obstructive sleep apnea. Resident #39 was admitted with diagnoses including obstructive sleep apnea, morbid obesity, diabetes mellitus, bladder cancer, and chronic kidney disease. The resident’s physician ordered assistance with putting on CPAP at bedtime for sleep apnea, but the resident’s care plan was silent regarding CPAP, and the Treatment Administration Record did not document the ordered assistance for the months reviewed. The resident’s family-provided CPAP report showed the machine was worn only on two nights during the reviewed period. The resident stated that staff failed to put the CPAP on nightly and that she was unable to complete the task herself. She reported feeling lethargic and tired during the day and said she had requested staff assistance, but it was not always provided. During an early morning observation, the resident was found sleeping with the CPAP sitting on the nightstand and not applied. A CNA later confirmed that night staff failed to assist the resident with putting on the CPAP. The facility policy on Respiratory Services directed staff to place the mask interface on the resident and ensure safety and comfort.
Incomplete Investigation of Resident Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation into Resident #53’s allegation of verbal and physical abuse by CNA #240. Resident #53 was admitted on 11/15/24 with diagnoses including cerebral infarction, restless leg syndrome, and major depressive disorder, and his quarterly MDS dated 02/20/26 showed moderately impaired cognition. During a complaint investigation, Resident #53 told an ODH surveyor that a staff member spoke unkindly to him, and later told LSW #231 that CNA #240 was very rough with cleaning him and was very strong, and that he felt CNA #240 did not like her job or him. The facility’s investigation contained only one statement from LSW #231 and did not include statements from CNA #240 or Resident #53. The facility did not complete a physical assessment after the allegation, did not interview like residents, and did not suspend CNA #240 during the investigation; CNA #240 continued working on the unit where Resident #53 resided. The facility concluded the allegation was unsubstantiated on 03/06/26 and documented that CNA #240 received education on patient handling, while the DON and Administrator later verified there was no further investigatory documentation for the allegation.
Missing Documentation for Incontinence Care
Penalty
Summary
The facility failed to ensure resident medical records were accurate when documenting incontinence care provided to residents. Based on staff interview and medical record review, incontinence care documentation was missing for three residents reviewed for medical record accuracy, and the Administrator verified that if a care task is not documented as completed, it cannot be verified as complete. Resident #33 was admitted on 07/20/22 and had diagnoses including stage three chronic kidney disease, morbid obesity, neuromuscular dysfunction of the bladder, polyneuropathy, and adult failure to thrive. The annual MDS dated 04/20/26 showed cognition was intact. The resident was dependent on staff for toileting and was frequently incontinent of both bowel and bladder. Review of incontinence care documentation for March, April, and May 2026 showed multiple dates with no documentation that incontinence care was provided. Resident #52 was admitted on 06/01/24 and had diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms and dementia. The quarterly MDS dated 03/31/26 showed cognition was moderately impaired. The resident required moderate assistance with toileting and was always incontinent of both bowel and bladder. Resident #90 was admitted on 01/13/23 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, memory deficit following cerebral infarction, and frontal lobe and executive deficit following cerebral infarction. The quarterly MDS dated 04/20/26 showed cognition was severely impaired, and the resident required assistance with toileting, was occasionally incontinent of bladder, and always incontinent of bowel. For both residents, review of incontinence care documentation across March, April, and May 2026 showed multiple dates with no documentation that care was provided, and the Administrator confirmed the missing documentation during interview on 05/28/26 at 3:30 P.M.
Failure to Complete Ordered Wound-Vac and Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatments and to complete wound care as prescribed for one cognitively impaired resident with unhealed pressure ulcers and multiple comorbidities, including diabetes mellitus, osteomyelitis, COPD, and need for assistance with personal care. Physician orders directed specific daily wound care to the right ischium and detailed negative-pressure wound therapy (NPWT/wound-vac) procedures for a sacral wound, including dressing types, application steps, suction settings, and scheduled dressing changes three times weekly, with a wet-to-dry saline dressing as an alternative only if NPWT could not be maintained. The resident’s care plan included interventions for skin breakdown and pressure ulcers, such as treatments per order, monitoring effectiveness, repositioning, and use of a tilt-in-space wheelchair. Review of the Treatment Administration Records showed multiple missed wound treatments and NPWT applications, with no initials indicating completion of the wound-vac on one date in January and missed right ischium treatments and wound-vac dressings on several dates in February. A nurse confirmed that blank initials on the TAR meant the treatments were not completed. During observation of wound care, the wound-vac machine was found sitting in a chair rather than in use, and the dressing on the resident consisted of an ABD pad and gauze instead of the ordered wound-vac dressing. The resident stated the wound-vac should have been in place but could not recall when it was last used. An LPN reported last applying the wound-vac several days earlier, and the NP acknowledged concerns that some wound care had not been completed, noting that the wet-to-dry dressing was intended only as an alternative if the NPWT equipment was not functioning, and there had been no reports of equipment malfunction. The facility’s pressure injury policy stated a commitment to provide evidence-based treatments in accordance with current standards of practice for all residents with pressure injuries.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) policy by not wearing appropriate PPE during wound care for a resident on EBP. The resident had been admitted on 03/23/18 with diagnoses including diabetes mellitus, acute hematogenous osteomyelitis, COPD, and a need for assistance with personal care. A significant change MDS dated 01/24/26 documented that the resident was cognitively impaired and had unhealed pressure ulcers. On 03/02/26 at 10:01 A.M., surveyors observed EBP signage on the resident’s door indicating that all staff and providers must wear a gown and gloves for high-contact resident care activities, including wound care and catheter care, and a PPE cart was available outside the room. The resident was observed to have a suprapubic catheter and a wound. Despite the posted EBP requirements, at approximately 10:01 A.M. LPN #440 entered the room, washed her hands, donned only clean gloves, and proceeded to position the resident and remove the old sacral wound dressing, discarding it in the garbage. LPN #440 then cleaned her hands and continued to cleanse the sacral wound without donning a gown. At 10:13 A.M., CNA #410 entered the room, donned clean gloves only, and assisted the LPN with positioning the resident by holding him on his side to allow better access to the wound, again without wearing a gown. In a follow-up interview at 10:32 A.M., LPN #440 confirmed that the resident was on EBP for both wounds and a urinary catheter and acknowledged that neither she nor the CNA had donned the appropriate PPE while providing wound care. Review of the facility’s EBP policy, revised 09/25, showed that residents with chronic wounds such as pressure ulcers and indwelling devices such as urinary catheters require EBP, and that high-contact resident care activities, including wound care and device care, require use of gown and gloves.
Failure to Remove Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to prevent further potential abuse during the investigation of an allegation of sexual abuse when the alleged perpetrator, an LPN, was allowed to continue working on the same unit while the investigation was ongoing. The incident involved a resident with severe cognitive impairment who was reported by another resident to have been touched on the chest by the LPN while being awakened for medication. The reporting resident did not witness the event but relayed the alleged victim's statement. The administrator was informed of the allegation and contacted the LPN and the resident's family, but did not immediately report the incident to the state agency and did not suspend the LPN during the investigation. The LPN continued to work multiple shifts on the same unit after the allegation was made, potentially affecting 36 residents residing on the unit. The facility's policy required immediate action to protect residents from further harm during investigations, including staffing or room changes if necessary. However, the LPN remained on duty while the investigation and resident assessments were still in progress. The administrator confirmed that interviews with alert and oriented residents were conducted and that skin assessments for cognitively impaired residents were ongoing at the time of the survey.
Failure to Notify Physician of Alleged Abuse Incident
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident with severe cognitive impairment and multiple diagnoses, including dementia, depression, and anxiety. An allegation was made that a male LPN had inappropriately touched the resident's chest while attempting to administer medication. The incident was reported by another resident and communicated to the Administrator by the LPN, and the resident's Power of Attorney requested that the LPN not return to the room. The Administrator initiated an investigation and spoke with the involved parties, including the resident, who appeared confused during questioning. Despite the facility's policy requiring physician notification for significant changes in condition or allegations of abuse, there was no documentation in the medical record that the physician was notified of the alleged incident. The Administrator confirmed that although she had notified the physician, this was not documented, and the involved LPN was unsure of the requirement to notify the physician. Nurse's notes for the relevant period did not reflect any physician notification regarding the allegation.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Notify Resident and Family of Medication Discontinuation
Penalty
Summary
The facility failed to inform a resident and their family about the discontinuation of a seizure medication, Phenytoin Sodium (Dilantin), which was ordered to be stopped based on recommendations from the facility pharmacy and the attending physician. The resident, who was cognitively intact with a BIMS score of 13, had a complex medical history including conditions such as hypertensive urgency, schizophrenia, COPD, and seizures. Despite the significant change in medication, there was no documentation or evidence that the resident or their family was notified about the discontinuation of the medication. Interviews with the facility's Administrator, Director of Nursing, and the resident's daughter confirmed that neither the resident nor the family was informed about the medication change. The physician involved also acknowledged that no discussion took place with the resident or family regarding the discontinuation. This oversight was in direct violation of the facility's policy titled 'Notification of Changes,' which mandates notification in circumstances such as the discontinuation of current treatment. This deficiency was identified during an investigation under Complaint Number OH00157606.
Infection Control Deficiency in Catheter Bag Maintenance
Penalty
Summary
The facility failed to adhere to infection control policies and procedures concerning the maintenance of urinary catheter bags for two residents. Resident #50, who is cognitively intact with a BIMS score of 14, was observed with his urine collection bag lying on the floor while he was seated in his chair. This observation was confirmed by a registered nurse, indicating a lapse in maintaining proper hygiene and infection control standards. Similarly, Resident #87, who is severely cognitively impaired with a BIMS score of 03, was observed being pushed in a manual wheelchair with his urine collection bag dragging on the ground. This was verified by a licensed practical nurse, further highlighting the facility's failure to ensure proper catheter care. The facility's policy, dated 2014, mandates appropriate catheter care and the maintenance of dignity and privacy for residents with indwelling catheters, which was not followed in these instances.
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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 Sandusky
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ohio Veterans Home | 1.7 mi | ★★★★★ | 5 | 1 |
| Concord Care And Rehabilitation Center | 2 mi | ★★★★★ | 0 | 0 |
| Parkvue Health Care Center | 3.4 mi | ★★★★★ | 11 | 0 |
| The Meadows At Osborn Park | 4.2 mi | ★★★★★ | 2 | 0 |
| Admirals Pointe Nursing & Rehabilitation | 6.8 mi | ★★★★★ | 0 | 0 |
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