Providence Seward Mountain Haven

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, or treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred. Specifically, the facility failed to obtain informed consent (a process where a patient or their representative was provided with the necessary information to make an informed decision about the use of medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1) accurate information regarding the grievance officer was available to the residents and 2) residents could file a grievance anonymously. This failed practice denied all residents and their representatives (for a census of 39) the right to file a grievance while maintaining confidentiality and having the grievance resolved.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respect and dignity were provided to 1 resident (#11) out of 12 sampled residents. Specifically, the Licensed Nurse (LN) #1 failed to provide privacy during administration of topical medications to the resident. This failed practice denied the resident of his/her right for respect and dignity.

Inspectors wroteBased on record review and interview, the facility failed to provide written notice of bed-hold policy upon an emergent transfer to the hospital of 1 resident (#38), out of 12 sampled residents. This failed practice denied the resident of the facility's bed-hold policy, placing the resident at risk for losing his/her bed at the facility due to an extended stay at the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and medical supplies were labeled and stored in accordance with acceptable professional principles for 19 residents (#s 1, 3, 4, 5, 10, 13, 14, 18, 22, 23, 24, 25, 29, 31, 32, 33, 36, 37, and 38) out of 19 residents who resided in Eagle and Lupine lodges. Specifically, the facility failed to: 1) discard expired medical supplies in 1 medication room (Lupine Lodge) out of 4 medication rooms inspected in the facility. 2) discard expired medical supplies in 1 medical supply storage room (Lupine Lodge) out of 4 medical supply storage rooms inspected in the facility, and 3) store insulin pens with prescription labels and protected barriers in 2 medication carts (Eagle and Lupine lodges) out of 4 medication carts inspected in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety for 18 residents (#s 2, 10, 11, 16, 17, 18, 19, 20, 21, 24, 25, 27, 29, 31, 32, 37, 39, and 40) who received food from the Lupine and Raven lodges' kitchen out of 20 residents that resided in the lodges. This failed practice had the potential to place the residents at risk of receiving contaminated food and food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control and prevention practices were observed during resident care for 1 unsampled resident (#20) out of a census of 39 residents. Specifically, 1) the Certified Nurse Assistants (CNAs) failed to change soiled gloves before moving from dirty areas to clean areas and 2) CNAs failed to perform hand hygiene between glove changes. This failed practice placed the resident at an increased risk for transmission of disease and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure final investigation results were reported to the State Agency for five Facility Reported Incidents (FRIs -AK 4446, 4485, 4486, 4487, and 4498) out of six FRIs within the mandatory reporting period. This failed practice had the potential to place all residents (based on a census of 39) at risk of abuse or neglect, and harm.

Inspectors wroteBased on interview and observations, the facility failed to ensure the contact information of advocacy groups was posted in location accessible to residents and their representatives in one lodge (#1), of 4 lodges observed during survey. This failed practice denied the residents and their representatives the contact information for State and local advocacy groups.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure: 1) storage of food under sanitary conditions, and 2) dietary staff protected food from cross contamination during the preparation of ready-to-eat foods in 2 of 4 lodges observed. This failed practice placed the 18 residents, receiving food from the kitchens, at risk for possible food borne illness and/or degradation in food quality.

Inspectors wroteBased on record review, observation, and interview the facility failed to implement measures identified in 1 resident's (#9) comprehensive care plan, out of 13 sampled residents. This failed practice placed the resident at risk of not receiving interventions designed to prevent injury from falls.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan was revised to reflect the resident's status for 1 resident (#33), out of 13 sampled residents. This failed practice placed the resident at risk for not receiving the necessary services and interventions to preserve or improve mobility.

Inspectors wroteBased on record review, observation, and interview the facility failed to provide a program of meaningful activities to 2 residents (#s 9 and 37), out of 13 sampled residents, based on an individualized assessment and care plans. This failed practice denied the residents opportunities that contributed to quality of life and placed them at risk for depression, loneliness, and boredom.

Inspectors wroteBased on record review, observation, and interview the facility failed to: 1) ensure devices and restorative exercises were utilized consistently to prevent further decline in range of motion (ROM); and 2) provide interventions to improve or preserve mobility after a significant decline in status. This failed practice had the potential to prevent 2 residents (#'s 18 and 33), out of 13 sampled residents, from maintaining their highest practicable level of ROM and mobility.

Inspectors wroteBased on observation and interview, the facility failed to ensure survey reports were readily accessible to residents and resident representatives, and notification of the availability of 3 years of survey results was posted and located in a prominent place. This failed practice denied all residents (based on a census of 38), and their representatives', information about the facility's performance and any identified concerns.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure three (Resident #6, Resident #26, and Resident #28) of six residents reviewed for unnecessary medications who had an order for an as-needed (PRN) antipsychotic medication did not extend beyond 14 days, without a physician assessment or were not extended without a Stop Date of no more than 60 days without documentation, as to the need for the PRN medication, as required. This failure placed the residents at risk of adverse side effects from unnecessary medications.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure a thorough investigation was completed for one of one facility reported incidents (FRIs) regarding alleged staff to resident abuse. This had the potential to affect one resident (Resident #91) of one reviewed for alleged staff to resident abuse.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to revise one of one resident's (Resident #13) plan of care related to falls to ensure appropriate care and interventions were included to potentially prevent further falls.

Inspectors wroteBased on observation, interview, record review, review of facility investigations and review of facility policy, the facility failed to ensure a thorough investigation was completed regarding an elopement for one of two residents (Resident #36) reviewed for elopements. The facility further failed to complete thorough investigations and ensure appropriate interventions were updated for one resident of one reviewed for falls (Resident #13).

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents reviewed for flu/pneumonia vaccinations (Resident #18) and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R18 the opportunity to be vaccinated with PPSV23 (pneumovax23®).