Every finding on record at Providence Seward Mountain Haven

.Based 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. This includes understanding the potential benefits, risks, and alternatives associated with the medication, as well as the right to withdraw consent at any time) prior to administering psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants that would have affected behavior, mood, thoughts, or perception) for 4 residents (#'s 1, 3, 4 and 5), out of 6 sampled residents. This failed practice violated the residents', or resident representatives' right to be informed of, and participate in, the residents' treatment. Findings: Resident #1Record review on 2/9-11/26 revealed Resident #1 was admitted to the facility with diagnoses that included severe dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking) with psychotic disturbance (where individuals lose touch with reality such as hallucinations, delusions, and disorganized thinking), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), and depressive disorder (a persistent feeling of sadness and loss of interest). Further review revealed Resident #1 had an Office of Public Advocacy (OPA) Guardian who made medical decisions for him/her. Review of Resident #1's Minimum Data Set (MDS - a federally required nursing assessment) admission assessment, dated 11/12/25 revealed, . Antipsychotic Medication Review. A. Did the resident receive antipsychotic medication since admission/entry or reentry or the prior OBRA [Omnibus Budget Reconciliation Act, a federal nursing home reform act] assessment, whichever is more recent? Yes- Antipsychotics were given on a routine and PRN [as needed] basis. Medication administration Review of Resident #1's medical record revealed the following psychotropic medications were ordered between 11/5/25 through 12/12/25 and that 288 separate administrations of these medications were given in this 37-day time period: Divalproex (Depakote - a mood stabilizer medication)39 administrations between 11/11-24/25 of divalproex 250 mg (milligrams) three times daily, oral. Ordered 11/10/25;22 administrations between 11/24/25-12/10/25 of divalproex, 500 mg three times daily, oral. Ordered 11/24/25; and33 administrations between 12/1-10/25 of divalproex 500 mg four times daily, oral. Ordered 12/1/25. Lorazepam (Ativan - an anti-anxiety medication) 5 administrations between 12/9-12/25 of lorazepam liquid 2 mg every 6 hours, as needed, oral. Ordered 12/9/25. Olanzapine Zydis (Zyprexa - a dissolvable tablet anti-psychotic medication)9 administrations between 12/1-9/25 of olanzapine zydis, 5 mg daily in the evening, oral. Ordered 12/1/25; 7 administrations between 11/10-30/25 of olanzapine zydis, 5 mg nightly, as needed, oral. Ordered 11/5/25. Quetiapine (Seroquel - an anti-psychotic medication)6 administrations between 12/8-10/25 of quetiapine, 100 mg four times daily, oral. Ordered 12/8/25; and 98 administrations between 11/5/25 - 12/8/25 of quetiapine 75 mg three times daily, oral. Ordered 11/5/25. Sertraline (Zoloft - an antidepressant medication)35 administrations between 11/6/25 - 12/10/25 of sertraline 100 mg daily, oral. Ordered 11/5/25. Trazodone (Desyrel - an antidepressant medication)34 administrations between 11/5/25 - 12/9/25 of trazodone 100 mg nightly, oral. Ordered 11/5/25. Further review of Resident #1's medical record revealed no documented informed consents for any of these psychotropic medications administered. Review of Resident #1's IDT [Interdisciplinary Team] Care Conference note, dated 11/5/25 and effective from 11/5/25 to 11/19/25, revealed: Nursing Assessment: MD [medical doctor] visits. 11/10 [November 10, 2025]: [spouse] requesting something else for [his/her] anxiety and agitation. Depakote ordered 250 mg three times a day. Resident #1's spouse was not his/her decision maker and there was no proof in the medical record the OPA Guardian was contacted to give approval for the Depakote administration. During the course of this survey, the facility was asked to provide proof that informed consent was obtained for Resident #1's psychotropic medications. The facility only provided two emails: 1. Email #1: Subject line: Mt Haven #secure#, between the MDS coordinator and the resident's OPA Guardian, dated 11/13/25 at 12:15 PM, revealed: [Provider] saw [Resident #1] 11/11 [November 11, 2025] and ordered Depakote. [He/she] is impulsive and high risk for falls. [He/she] is taking Depakote 250mg 3 times a day. [Provider] will be seeing [him/her] every 2 weeks at this time as [he/she] is taking a PRN antipsychotic and a scheduled antipsychotic. I did not see specific documentation you were notified about the Depakote. if you were and this was a duplicate I apologize. Further review of the email revealed the guardian was not informed of the risks and benefits of Depakote, treatment alternatives, or other options, nor was the guardian given the opportunity to choose a preferred option on behalf of the resident. 2. Email #2: Subject line: Re: PSMH [Providence [NAME] Mountain Haven] Important Update Regarding Resident #secure#, between the LTC Nurse Manager (LTCNM) and the resident's OPA Guardian, dated 12/9/25 at 10:22 AM, revealed medication adjustments were made because of escalating behaviors: . Olanzapine: changed to 5mg scheduled every evening (from as needed). Depakote: increased to 500mg PO [by mouth] four times daily. Quetiapine: increased to 100mg PO [by mouth] four times daily. Further review of the email revealed the guardian was not informed of the risks and benefits of the discussed medications, treatment alternatives, or other options, nor was the guardian given the opportunity to choose a preferred option on behalf of the resident. The facility did not provide any documented informed consents for any psychotropic medications administered to Resident #1. During an interview on 2/10/26 at 2:47 PM, Resident #1's OPA Guardian stated the facility had never reviewed the risks and benefits, treatment alternatives, or other options, or was given the opportunity to choose a preferred option on behalf of the resident for any of the resident's medications. During an email on 2/11/26 at 10:57 AM, the OPA Guardian stated that if the risks and benefits of the medications were provided, it would have guided the decision making. Resident #3Record review on 2/9-11/26 revealed Resident #3 was admitted to the facility with diagnoses that included vascular dementia (dementia from reduced brain blood flow, often due to strokes), and cerebral vascular disease (blood vessel disorders in the brain causing reduced flow or strokes). Further review revealed Resident #3 had an OPA Guardian who made medical decisions for him/her. Review of Resident #3 MDS, quarterly assessments dated 6/3/25, 9/2/25, and an annual assessment dated [DATE], revealed Resident #3 was taking, . High-Risk Drug Classes. K. Anticonvulsant. C. Antidepressants [assessed only on 12/3/25]. Medication Administration Review of Resident #3's medical record revealed the following psychotropic medications were ordered between 7/8/25 through 2/10/26 and that 616 separate administrations of these medications were given in this 217-day time period: Mirtazapine (Remeron - an antidepressant medication)28 administrations between 10/16/25 and 11/17/25 of mirtazapine, 7.5 mg tablet, Oral - Frequency: NIGHTLY. Ordered 10/16/25 (Discontinued on 11/18/25);Valproic acid (liquid Depakote, called Depakene - a mood stabilizer medication)585 administrations between 7/8/25 and 2/10/26 of valproic acid, 250 mg/5 mL (milliliters) liquid - Dose: 250 mg, Oral - Frequency: 3 TIMES DAILY AFTER MEALS. Ordered 6/1/25 (date the order was active). Further review of Resident #3's medical record revealed no documented informed consents for any of these psychotropic medications administered. Review of Resident #3's, Progress Note, dated 10/17/25, revealed Licensed Nurse (LN) #2 wrote: Unable to reach Resident #3 representative. Copy of notes including addition of Remeron to med [medication] list sent to Resident's Representative in regular mail. No email option. Further review revealed no other progress notes that documented additional efforts to contact the resident representative to discuss medications. During an email on 2/11/26 at 10:57 AM, the OPA Guardian stated that if the risks and benefits of the medications were provided, it would have guided the decision making. During the course of this survey, the facility was asked to provide proof that informed consent was obtained for Resident #3's psychotropic medications. The facility did not provide any proof. Resident #4Record review on 2/9-11/26 revealed Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease with dyskinesia (involuntary muscle movements), dementia due to Parkinson's disease with behavioral disturbance (cognitive decline with psychiatric features), hallucinations (psychotic symptoms), and moderate Lewy body dementia (a brain disorder characterized by abnormal protein deposits that cause progressive cognitive decline) with psychotic disturbance. Further review revealed Resident #4 had a resident representative who made medical decisions for him/her. Review of Resident #4's MDS quarterly assessment 12/22/25 revealed Resident #4 was taking .High-Risk Drug Classes.A. Antipsychotic.B. Antianxiety.K. Anticonvulsant. Medication Administration Review of Resident #4's medical record revealed the following psychotropic medication was ordered on 11/13/25 through 2/11/26 and that 86 separate administrations of this medication were given in this 90-day time period:Pimavanserin (Nuplazid - an anti-psychotic medication)86 administrations between 11/16/25 and 2/11/26 of pimavanserin 34 mg capsule, Dose: 34 mg, Oral - Frequency: DAILY. Ordered 11/13/25 (Scheduled to start on 11/16/25; order active). Further review of Resident #4's medical record revealed no documented informed consent for this psychotropic medication administered. During the course of this survey, the facility was asked to provide proof that informed consent was obtained for Resident #4's psychotropic medication. The facility did not provide any proof. Resident #5Record review on 2/9-11/26 revealed Resident #5 was admitted to the facility with diagnoses that included dementia with behavioral disturbance and Parkinson's disease. Review of Resident #5's physician orders revealed the provider ordered Seroquel on 1/12/26 at 9:00 PM: . QUEtiapine (SEROquel) tablet 25mg.oral. nightly. Review of Resident #5's medical record revealed this Seroquel medication was first administered to Resident #5 on 1/13/26 at 8:16 PM. Review of Resident #5's Providence [NAME] Mountain Haven Psychotropic Risk/Benefits Verification of Informed Consent, dated 1/14/26 at 1:33 PM, revealed: LIST of Residents current PSYCHOTROPIC MEDICATIONS. Medication: Quetiapine (Seroquel). Dosage: 25 mg [milligrams]. Route: PO [by mouth]. Frequency: Nightly. Diagnosis: Parkinson's disease with dyskinesia and fluctuating manifestations. EXPLANATION OF RISK AND BENEFITS PROVIDED BY [Long Term Care Nurse Manager] on 1/14/2026 to the following: Representative. This informed consent was obtained one day after the medication was already administered to the Resident. Informed Consent Process Interviews During an interview on 2/11/26 at 11:38 AM, LN #4 stated that he/she believed the physician was ultimately responsible for obtaining informed consent for medications from the resident or resident representative. He/she stated, .when there are medication changes, such as dose adjustments, discontinuations, or changes from one medication to another, the physician would obtain consent and staff would notify the resident or Power of Attorney of the changes. LN #4 was unsure where the signed medication consents were stored in the resident's medical record. During an interview on 2/11/26 at 11:40 AM, LN #6 was not sure who was responsible for obtaining informed consent, when to obtain an informed consent, or where informed consents were kept in the resident's medical record. LN #6 stated he/she did not know how to verify if an informed consent was present prior to administering a new medication. The LN further stated that only antipsychotics needed consent and if the question came up he/she would call the nursing supervisor and ask. During an interview on 2/11/26 at 11:51 AM, LN #5 stated the resident was responsible for providing consent for medications. If the resident had a representative, then that individual would provide consent on the resident's behalf. Consent was obtained during the admission process, documented in the electronic medical record (EMR), and management handled much of the admission paperwork. LN #5 further stated that he/she assumed that since the physician wrote the medication orders, the physician had obtained informed consent before writing the order. He/she identified psychotropic medications and antipsychotics as requiring informed consent, and that included discussion of risks and benefits. During an interview on 2/10/26 at 4:10 PM, the Director of Nursing (DON) and the LTCNM stated when the doctor placed new orders for medications that needed consent, the LN at the bedside would be notified via the electronic medication administration record (EMAR) that a new medication was ordered. The LNs were trained to obtain informed consent prior to giving the first dose. There was also an online reference for the LNs. The DON further stated that the facility did not obtain informed consent for psychotropic medications if a resident was already taking the same medication when admitted , because the resident was assumed to know the risks and benefits. During an interview on 2/11/26 at 12:33 PM, the LTCNM stated it was the responsibility of the nurse assigned to the resident's cottage to obtain informed consent for psychotropic medications prior to the medication's first administration. The LTCNM further stated that the facility would email resident representatives or guardians for medication consents, however, copies of those emails were not placed in the residents' medical records. The LTCNM further stated she had audited the electronic records for informed consents; however, the audits had not occurred regularly. The gap was recently identified, and the facility had since filled two nurse supervisor positions to assist with consent audits. When a missing informed consent was identified, the facility obtained it immediately. Review of the facility resident rights document As a Resident, you have the Right, Revision 4/2024, revealed: . Further, you have the right to be informed in advance of any change in care or treatment that may affect your well-being. This includes being told of the benefits and reasonable risks of treatment, and about the reasonable available alternatives. Review of the facility policy PSMH Psychopharmacological Drug Use and Gradual Dose Reduction, last revised 3/2024, revealed, . General Provisions: 1. Residents or their representative are advised of potential risks versus benefits of psychotropic medication therapy. PROCEDURE. C. Licensed Nursing staff: 1. Advise the resident or resident's representative of potential benefits and side effects of Psychotropic medication therapy, and document risk/benefit information has been provided on the Psychotropic Risk/Benefit documentation sheet.

Based 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. Findings: Grievance Official Information: Review of the Providence [NAME] Mountain Haven [PSMH] - Resident Handbook 2022/2023, with the Admission Coordinator (AC), revealed on page 27 the PSMH Grievance Official (GO) listed was GO #1. The current GO was GO #2, who was the Quality Improvement Coordinator (QIC). During an interview on 9/12/24 at 10:00 AM, the QIC stated he/she was in charge of all the grievances. He/she provided the surveyors with documentation regarding Resident Rights. The QIC stated resident rights were given to residents on admission in a packet and stated he/she did not realize that some of the paperwork did not have the correct grievance officer's name. When describing the process of filing a grievance, he/she stated that the caregiver would offer to give help to the residents fill out the complaint form if the resident was not able to fill out the form on their own. The QIC stated the binder was accessible to all residents in the dining area. The QIC also stated once the grievance was received, he/she would follow up on it in person with an interview, then he/she would write a letter to the resident and/or their guardian with the resolution of the grievance. He/she added that's dependent on the level of the complaint or if there was abuse. During an interview on 9/11/24 at 3:00 PM, when asked Social Services (SS) #2 about the grievance officer listed in the resident handbook, he/she stated: oh yeah, I didn't realize that GO#1 left us. SS #2 further stated I couldn't tell you when he/she left, maybe less than a year. SS #2 confirmed the Providence [NAME] Mountain Haven- Resident Handbook 2022/2023, was currently being used with new admissions. During an interview on 9/12/24 at 9:00 AM at the Fireweed lodge with LN#72, regarding the question: Who is the grievance officer? He/she stated: I don't really know, I would have to get back to you on that, but in the past if I have a grievance, I would call the social worker to get in here and handle it. The same nurse was unaware of the grievance box being used for that purpose and stated, that box in the corner is for suggestions only. During an interview on 9/12/24 at 11:11 AM with LN #69, at the Raven lodge regarding the question: Who is the grievance officer? He/she stated: If I am in Alabama, I know their names but now I don't know their names. Oh my God I don't know. During a same day interview at 11:40 AM, CNA #9 at the Eagle Lodge stated: First you tell the nurse and then .[name of unknown staff #1]. During a simultaneous interview on 9/12/24 at 12:25 PM at the Lupine Lodge, regarding the question: Who is the grievance officer? CNA #8 stated the grievance officer was the social worker. LN #3 stated he/she checked the board, and the grievance officer was [name of unknown staff #2]. Review of the policy and procedure titled, Resident Complaints/Concerns and grievances, last revised on 4/2024 revealed: . C. The facility must make information on how to file a grievance or complaint available to the resident. The facility must also make available the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number . Filing of Grievance anonymously: During a meeting with the Resident Council on 9/11/24 at 1:30 PM, when residents were asked the question: do you know how to file a complaint or grievance?, 10 residents (#s7, 10, 16, 26, 27, 28, 29, 31, 32, 37) out of 11 residents who attended the meeting stated they did not know how to file a grievance. Resident #19 was aware of the process to file a grievance. During an interview on 9/11/24 at 2:30 PM, the QIC was unaware that residents did not know how to file a grievance. During an interview on 9/11/24 at 3:00 PM, with SS #2 who also served as the AC, he/she stated that residents typically get informed on grievances when they receive their Resident Handbook which happens after they arrive to the facility and/or is sent to their representatives/families after admission. Review of the document titled: Feedback/Communication, no date, filed in the binder titled Resident Concerns/Complaints/Feedback - Providence Mountain Haven, that was kept on the counter of each dining area of each lodge, revealed: residents have the right to submit concerns anonymously. During random observations from 9/9-13/24 in all lodges, revealed square wooden boxes titled, Suggestion box, were on the counters in the dining areas. These boxes were unlocked. Review of the policy and procedure titled, Resident Complaints/Concerns and grievances, last revised 4/2024 revealed: .6) Anyone [staff member, resident, visitor, family member, or resident representative, etc.] may request and complete a Feedback/Communication form for any reason. The forms are in the binder, location has been determined by residents in the lodge for their access. Concerns and grievances may be submitted anonymously by submitting it into a box in hearth area of each lodge .

43792 50031 50078 Based 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. Findings: Resident #5 Record review on 9/9-13/24 revealed Resident #5 was admitted to the facility with a diagnosis that included Alzheimer's disease (a progressive mental deterioration, due to generalized degeneration of the brain) with late onset. During an interview on 9/13/24 at 9:28 AM, the Director of Nursing (DON) stated LN #34 struggled with completing initial and final reports in a timely fashion. Review of the Adult Protective Services Intake Report (APS), dated 11/3/23 at 6:14 PM, revealed an initial report sent to the State of an incident that occurred on 10/31/23 at 5:30 PM. This report was completed by Licensed Nurse (LN) #34. According to this report, Resident #5 was assisted to the floor by CNA (Certified Nursing Assistant) #44. There was no injury reported at this time. On 11/1/23, a new bruise was noticed on the Resident's knuckle, and the Resident reported left hip pain at this time also. On 11/2/23, the Resident had a bruise on the left hand and wrist. On 11/3/23, it was reported from LN #71 that Resident #5's left leg was shorter than the right and there was significant pain. LN #73 reported this to the physician. On 11/3/23, the physician assessed the Resident and then diagnosed a left femur fracture and sent the Resident to the emergency room for evaluation. Review of the Initial Report to the State dated 11/3/23 at 6:41 PM and completed by LN #34 revealed a witnessed fall on 10/31/23 at 5:00 PM which resulted in CNA #44 assisting the Resident to the floor upon difficulty with the Resident's ambulation due to weakness. The report revealed that the knuckle on left hand was bruised on 11/1/23, bruising occurred on 11/2/23 to the left wrist, and then on 11/3/23, bruising was seen on the left hip with left leg shortening and inner rotation and left hip swelling occurring. The Resident was sent to the emergency room for evaluation and then sent to an Anchorage hospital for a left leg fracture repair. Review of the facility's Final Report for Resident #5, dated 12/6/23 for date and time of the incident, was completed by LN #34 on 12/11/23. This report revealed the Resident was found to have an unopened left heel blister measuring 4 cm x 4 cm. Also included on this report were details about the 10/31/23 fall which resulted in a left femur fracture which required a hospitalization and surgery. This final report was completed after the five-day final reporting requirement since it was completed 1 month and 3 days after the incident occurred. Resident # 19 Record review from 9/9-13/24 revealed Resident #19 was admitted to the facility with diagnosis of anoxic (lack of oxygen) brain damage. Record review of the FRI, incident happened on 12/15/23, and revealed the Facility Administrator found Resident #19 outside of the Raven lodge (where resident resided) screaming .in a wheelchair, feet out with [a] blanket on his/her lap, covered with snow . Review of the Final Report, dated 3/5/24, revealed the facility investigated the incident and found out that . [Resident #19] prefers to be outside to cool down from a hot flash. The Resident was left outside unattended without direct supervision and was not provided with a way to alert the staff for assistance. The final investigation further revealed . The event did not cause any injury; however, staff were interviewed, and education to staff provided on direct supervision when residents are outside and providing proper tools for the Resident to communicate with the staff for safety concerns. The final investigation was reported to the State on 3/5/24, 3 months after the incident occurred. Resident #22 Record review on 9/9-13/24 revealed Resident #22 was admitted to the facility with a diagnosis of Alzheimer's disease (a progressive mental deterioration, due to generalized degeneration of the brain) with late onset. During an interview on 9/13/24 at 10:00 AM, the DON stated LN #34's incident reports were not completed in a timely manner. Review of the facility's Initial Report, for Resident #22, date of report 12/13/23 with unknown time, was completed by LN #34. This report revealed an incident occurred on 12/10/23 at 7:21 PM. This report was sent to the State on 12/13/23. Further review of this document for initial reporting of the incident on 12/10/23 at 7:21 PM revealed: Issue: Multiple Stage II Pressure injuries noted on the sacrum measures approximately 0.6 x 1.5 cm. There are two other wounds on the buttocks, one is about 1 x 1 cm, and the other is approximately 2.5 x 0.7 cm. The inferior on the buttocks appeared to be shallow skin tears. Patient also has some mild erythema (skin redness) of the mid thoracic spine are in the midline of the spinous process (bony projection that extends from the back of each vertebra). Description of the event: 12/10/23 at 7:21 PM, completed by LN #72, revealed: I have examined the Elder's skin from head to toe and have noticed the following skin concerns . has open lesion(s) present in past 7 days. Elder has a new open area on [his/her] lumbar spine. Area is cleansed with wound cleanser. Mepilex[wound dressing] applied. Elder is placed on [his/her] side to offload area. Review of the facility's Final Report, for Resident's incident on 12/10/23 at 6:09 PM of skin concerns regarding the lumbar spine with red areas and an open area revealed this report was completed late. The final report was completed on 3/4/24 at 3:00 PM. This final report was to be completed 5 days after the incident, however this report was not completed until 2 months and 3 weeks past the original incident time and date. The wound had healed, and ongoing follow-up action completed showed the Resident was on an air mattress, the caregivers were educated on prevention of skin breakdown, keeping the skin areas clean and dry, and the Resident repositioned frequently, for the Resident's daily care. The final investigation was reported to the State on 3/4/24, 3 months after the incident had occurred. Resident #27 Record review from 9/9-13/24 revealed Resident #27 was admitted to the facility with diagnoses that included seizure disorder (epilepsy condition) and schizophrenia (mental disorder). During an interview on 9/12/24 at 10:00 AM, the Quality Improvement Coordinator and the DON both stated that the report was sent late, due to staff not fulfilling the duties of their position: the person doing the job wasn't actually doing it, so he/she stepped down and March of 2024 was when we finally got caught up with all the things, [he/she] didn't do. The DON also provided the internal investigation for this FRI: conclusion: no harm to the Resident was found during the investigation. CNA #6 was notified that he/she was to return to work as the investigation concluded, the caregiver resigned from her position. Per DON the resignation happened on 1/25/24, confirmed by the review of staff's schedule provided. Review of the Initial Report, date of report 3/4/24 was completed by LN #71. However, this allegation occurred on 1/17/24. This report was sent to the State on 3/7/24. Review of the Final Report, dated 3/4/24, revealed resident complained about . a CNA being rough with him/her during cares . Resident's representative was notified, and CNA #6 taken off the schedule and placed on administrative leave immediately. All caregivers working at the time of the report were interviewed, the resident was interviewed by nursing management, and other residents in the lodge were interviewed as well. The resident requires assistance from one caregiver to ambulate safely with a gait belt and walker. During interviews, the resident reported that he/she felt like he/she was being rushed by CNA #6 and felt like he/she was being challenged during exercises to complete them correctly. Specifically, the resident recalled a time he/she went to walk forward, and CNA #6 told him/her to try to take bigger steps instead of shuffling his/her feet, and the resident endorsed that he/she felt rushed because he/she made the same comment several times, and that his/her tone of voice was rough. The resident denied any harm, threats, or mistreatment by the caregiver and no harm was found during the investigation for reported possible mistreatment. The caregiver resigned from their position and did not return to work, although no harm was found during the investigation, and he/she was released from administrative leave. Although no harm was found during the investigation, education on prevention and reporting of Abuse, Neglect and Exploitation was provided to caregivers. The Resident was educated on where to locate and how to request the Resident complaint/grievance forms and provided the ombudsman contact information for reference. The final investigation was reported to the State on 3/7/24, 2 months after the incident occurred. Resident #32 Record review from 9/9-13/24 revealed Resident #32 was admitted to the facility with diagnoses that included impaired mobility (movement) and cerebrovascular accident (stroke). During an interview on 9/11/24 at 9:50 AM, CNA #8 responded to Resident #32's call light on 9/29/23. Resident #32 reported that CNA #43 was rough and hurt him/her when he/she was wiped with a washcloth up in his/her anus and felt violated. CNA #8 stated he/she informed LN #58, and the nurse manager. LN #71 contacted the [NAME] Police Department. CNA #8 stated he/she provided a report to the police. During a simultaneous interview conducted, on 9/11/24 at 11:00 AM, with the DON, the Administrator, and LN #11, the DON stated on 9/29/23, CNA #43 was immediately removed from the care areas and placed on administrative leave. The Resident's guardian was notified and arrived at the facility to remain with the Resident. The facilities medical director was also notified of the incident. [NAME] Police Department arrived on site on 9/29/23 to investigate the allegation. DON stated: [NAME] Police Department interviewed all caregivers, Resident, and Resident's guardian separately. The Resident was transported to Providence [NAME] Medical Center for an evaluation. CNA #43 remained on administrative leave until police investigation was completed. The Administrator stated the final investigation report should have been sent in 5 days, as per the five-day final reporting requirement. The DON further stated he/she received notification from [NAME] Police Department later the night of 9/29/23 or early on 9/30/23, regarding the investigation that no evidence was found, and no charges would be filed. On 10/3/23 CNA #43 returned to work and was assigned to a different lodge (Eagle Lodge). Record review of APS Report, dated 9/29/23 at 6:42 PM, revealed an allegation of physical abuse. Resident #32 reported that CNA #43 was rough and hurt him/her when he/she was wiped with a washcloth up in his/her anus and felt violated. The facility reported the incident occurred on 9/29/23 at 5:40 PM. LN #58 assessed the Resident. CNA #43 was removed from Resident care. LN #71 reported to DON, who contacted the [NAME] Police Department. This APS report was submitted by LN #71. Review of Providence [NAME] Medical Center, Emergency Department (ED), Provider Notes dated 9/29/23, revealed: Resident #32 was with frail skin and poor rectal tone. Provider explained with poor rectal tone, when someone was wiped over the anus it would feel like someone was pushing. The provider determined no signs on injury or trauma on exam. Review of Provider Notes, dated 10/2/23, during provider assessment, revealed: Resident #32 denied feeling being sexually assaulted and agreed with the ED provider's conclusion. The final investigation report was received on 10/12/23, 13 days after the incident. Review of facility's PSMH Abuse Prevention and Protection, last revised 12/2023, revealed: . b. Caregiver to resident abuse . The provider, state agency, family and/or resident representative, nursing administration, and the police will be notified as appropriate within 2 hours of the incident . f. Report the results of all investigations to nursing administration and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident .

Based 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. Findings: Record review from 9/9-12/24, revealed Resident #11 had diagnoses that included aphasia (a language disorder), unspecified signs and symptoms involving cognitive functions following cerebral infarction (stroke), and chronic pain (persistent discomfort). Review of the Quarterly Assessment Minimum Data Set (MDS - a federally required nursing assessment), dated 8/1/24, revealed in Section C - Cognitive Patterns, the response for brief interview for mental status was No (resident is rarely/never understood). Review of the Care Plan, dated 8/6/24, revealed Resident #11's needs and preferences . I have [a] problem communicating, being able to express myself.because I have expressive aphasia, I can say yeah but may not be reliable with my answers. An observation on 9/10/24 at 8:38 AM, revealed Resident #11 with 2 other residents (#16 and #39) were eating breakfast in the dining area. LN #1 approached Resident #11 and applied eye drops to each of the Resident's eyes. LN #1 then gave oral medications. After giving the oral medication, LN #1 applied topical medication to Resident's right hand. Then, LN #1 removed Resident's right shoe, pulled the sock halfway down and applied topical medication to resident's right ankle. Further observation revealed 3 other unidentified staff were in the area. The cottage was an open living lay-out where the dining area was visible to the kitchen and living room. The dining area was also visible from the patio through a glass wall. People could come and go in the lodge passing through the dining area. During an interview on 9/10/24 at 8:48 AM, when asked of the medication administered to Resident #11, LN #1 stated: Refresh Plus 1 drop per eye for dry eyes and Diclofenac Sodium 1% 4 grams applied to right hand and right ankle for pain. The LN further stated he/she was supposed to apply Diclofenac Sodium gel to Resident #11's right shoulder but the Resident was not cooperative. LN stated he/she planned to apply the medication after breakfast. At 8:49 AM, Resident #11 remained in the dining area after breakfast. LN #1 pulled Resident #11's shirt off to expose the shoulder and applied Diclofenac Sodium gel to Resident #11's shoulder. During an interview on 9/12/24 at 4:30 PM, when asked what the expectation for the nurse was in applying eye drops and topical medication to residents, the Director of Nursing (DON) stated It [eye drops and cream] should be administered inside the resident's room to provide privacy unless the resident chose to be given where they are at. Review of facility's policy PSMH (Providence [NAME] Mountain Haven) Medication administration, dated 1/2024, revealed: .Oral medications may be administered to residents at dining room table, if the resident [was] agreeable, however, medications by any other route must not be given at [the] dining room table to provide privacy and dignity. Review of the Providence [NAME] Mountain Haven Resident Handbook 2022/2023, revealed: Resident Rights. You have the right to be treated with dignity and respect .

Based 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. Findings: Record review from 9/9-13/24, revealed Resident #38 was admitted at the facility with a diagnosis of panlobular emphysema (respiratory disorder characterized by problems with fully exhaling air). Review of Nursing notes, on 9/9/24 at 9:28 PM, a nurse received an order to send Resident #38 to the emergency room (ER) for evaluation. On the same date, Resident #38's Durable Power of Attorney (DPOA) was informed of the resident being sent to ER . Review of facility's LTC Bed Hold Policy, last revised date 5/2022, revealed: . 4. Notice of Bed-Hold Guidelines for Transfers: a. Before a non-emergency transfer to a hospital or therapeutic leave, the facility will inform the resident and a family member or legal representative of the . [facility] guidelines on bed holds. This is accomplished using the Bed Hold Guidelines and Notice form . b. As soon as practical after an emergency hospital transfer the facility will inform the resident and resident representative of the facility's guidelines on bed holds. This is accomplished using the Bed Hold Guidelines and Notice form . Review of facility's Bed Hold Guidelines and Notice form, last revised date 10/2020, revealed: . It is a Federal Requirement (483.12(b) (1)) that we notify you in writing of our Bed Hold Policy upon admission and when you leave the facility for hospitalization or a therapeutic leave. This letter serves as that notification . Signature of Resident . Signature of Representative . During an interview on 9/12/24 at 4:10 PM, LN #3 stated he/she was not aware of a bed hold policy when a resident was transferred out of the facility. During an interview on 9/12/24 at 4:15 PM, LN#11 stated the bed hold form should have been printed off and placed in the packet with all the records being sent to the hospital with the resident. Then, the nurses should have documented in the electronic health record (EHR) that the bed hold policy was provided to the resident. During an interview on 9/12/24 at 4:30 PM, Social Services (SS #2) stated he/she should have called a resident's representative/guardian to discuss bed holds. However, SS #2 denied calling Resident #38's guardian to provide the bed hold policy.

50031 Based 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. This failed practice had the potential to place all residents in Eagle and Lupine lodges at risk of receiving expired supplies and adverse effects due to medication errors. Findings: Medical supplies: An observation, during the Lupine Lodge tour, on [DATE] at 7:55 AM, revealed expired medical supplies in the medical supply storage room: 1- 24 g. tube of toothpaste, Sparkle Fresh; manufacturer's expiration date was [DATE]. 1- Care Fusion, 001206, adult aerosol mask, manufacturer's expiration date was [DATE]. 1- Care Fusion, 001206, adult aerosol mask, manufacturer's expiration date was [DATE]. An observation, during the Lupine Lodge tour, on [DATE] at 8:20 AM, revealed expired medical supplies in the medication room: 15- ConvaTec, Aquacel Ag Advantage Enhanced Hydrofiber Dressing with Silver, 10cm x 12cm/4-inch X 5-inch, manufacturer's expiration date was [DATE]. Labeling and storage of insulin pens: An observation on [DATE] at 9:10 AM, of Lupine Lodge's medication cart, revealed a Lantus insulin pen in the right second drawer of the medication cart, stored with other resident's medication and medical supplies. The insulin pen was rolling around in the drawer, not in the original dispensing box or in a zipped bag. The only identification on the insulin pen was written in black marker on a 1.5- inch piece of clear tape, which included Resident #25's first name, open date of [DATE], and expiration date of [DATE]. Licensed nurse (LN)#3 stated the Lantus pen belonged to Resident #25 and was to be administered at bedtime. LN #3 stated this was how the medication had been stored but he/she further stated that it should be in a box and have a pharmacy label on it. During an interview on [DATE] at 3:30 PM, LN #11 stated that it was the facility's process to store together the medications which were administered with the same routes. Extra boxes of the medications were stored in the refrigerator. The instructions were kept as reference in the Medication administration record. During an interview on [DATE] at 4:00 PM, the Director of Nursing (DON) explained the process for storing the insulin pens and insulin boxes. She stated the insulin pens were kept in their original containers, and this was acceptable. An observation on [DATE] at 11:47 AM, of Eagle Lodge's medication cart, revealed two insulin pens were stored in the small compartment in the upper sliding drawer. In this drawer were stored 1 Basaglar Kwik Pen with the Resident #3's name and an open date of [DATE] handwritten in black marker. Also in this compartment was another insulin pen, Resident #23's Lantus Solostar injection with an opened date of [DATE] and expiration date of [DATE] handwritten in black marker. These insulin pens were not labeled with a prescription label and stored without the original dispensing boxes or zipped bag. These pens were not secured and could roll around easily. A second observation on [DATE] at 9:01 AM, revealed LN#3 opened the Lupine Lodge's medication cart's right second drawer. Lantus insulin pen was rolling around, not in the original dispensing box or secured in a zipped bag. The only identification on the insulin pen was written in black marker on a 1.5- inch piece of clear tape, which included Resident #25's first name, open date of [DATE], and expiration date of [DATE]. During an interview on [DATE] at 10:42 AM, the Pharmacist stated multidose medications were dispensed to the facility in the package supplied by the manufacturer. Insulin was supplied in the manufacturer's box with a pharmacy prescription label. The Pharmacist further stated if the prescription order was less than 3 pens, then the insulin pen(s) would be dispensed in a zipped baggie with a pharmacy prescription label. The Pharmacist stated medications were expected to have a prescription label attached which included the resident's name, physician, route, dosing, time, and name of medication. He/she further stated administering medications without a prescription label was not the best practice. The Pharmacist stated medications stored without a prescription label could cause a near miss medication error. He/she further stated insulin pens rolling around in the drawer was not a sanitary practice. The Pharmacist stated he/she had seen this practice in the past but further stated he/she will make changes. Review of the facility's policy PSMH Storage of Medication, last revised ,d+[DATE], revealed: B. Each resident's medications and topicals are stored separately from other resident's medications . 5. Improperly labeled, deteriorated, and expired items are not stored in medication areas . 12. Medications are stored in the packaging received from the pharmacy . Review of Lippincott procedure, last revised [DATE], accessed at https://procedures.lww.com/lnp/view.do?pId=5968053&disciplineId=12427, on [DATE], revealed: Compare the medication label to the order in the patient's medical record .

Based 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. Findings: Improper food labeling: During initial tour at the Raven Lodge kitchen on [DATE] at 2:00 PM, revealed the following opened food items in the refrigerator: 1-quart half and half, with no opened date and no use by date. 1- gallon 2% milk, with no opened date and no use by date. Further observation in the kitchen, revealed opened Simply thick it (a thickener added to residents' fluid or beverages) was on the counter. The [NAME] #1 stated he/she also used a powder thickener by showing Ready care instant thickener. These thickeners had no open date and no use by date label. During the initial tour on [DATE] at 2:00 PM, in the food storage room, a frozen mushroom soup was labeled ,d+[DATE], with no use by date. During an interview on [DATE] at 2:05 PM, [NAME] #1 stated the half and half and milk were opened today ([DATE]). He/she explained both food items go fast so they don't label an open date. The [NAME] also stated he/she would find out the expiration guideline for the mushroom soup. During initial tour at Lupine Lodge kitchen on [DATE] at 3:30 PM, revealed: 1- 16-ounce Custom Culinary, Beef Base, with no opened date or no expiration date. 1- 12- ounce Monarch, Honey, no opened date or no expiration date. 1- clear bag with brown bread slices, no opened date or no expiration date. 1- clear bag marked English Muffin containing 4 muffins, opened date [DATE] and no expiration date. During an interview on [DATE] at 4:09 PM with the Dietary Manager, when asked about the frozen mushroom soup expiration date, she stated she would find out. When asked about the thickener liquid and powder, she stated those items should have been labeled with opened date and expiration date. When asked about the half and half and milk, she stated she was not told to put opened date for half-half because they go through half and half in one day and rotates so fast. Expired food items: During initial tour at Lupine Lodge kitchen on [DATE] at 3:30 PM, revealed: 1) Dry Pantry: 1- 1.3-ounce, Nutri Grain raspberry bar, manufacturer's expiration date was, [DATE]. 1- 16-ounce, Custom Culinary, Low-Sodium Vegetable Base, manufacturer's expiration date was [DATE]. 1- 16-ounce, Glenview Farms, Sweet Cream Butter, Unsalted, packaging torn, no opened date, no used by date and no manufacturer's expiration date. 2) Lodge Kitchen: 3- ,d+[DATE] Sandwich made of brown bread, Item PB&J, Prepared Date, ,d+[DATE], Use By, ,d+[DATE], 1- 16-ounce Custom Culinary, Low-Sodium Chicken Base, covered with Saran wrap, opened date [DATE] and expiration date was [DATE]. Review of the facility's Food Storage Guidelines, undated, no reference, revealed: Refrigerated items. milk after opening, the expiration date was the date on the package. The guidelines further revealed the expiration date of half and half was the date in the package. There was no guideline for frozen mushroom soup. Review of facility's policy PSMCC [Providence [NAME] Medical Center] Food Receiving & Storage, Effective date ,d+[DATE], revealed: . Label & date foods that have been .opened with 'opened on' and 'use by' date. Review of United States Department of Agriculture (USDA), How long can you keep dairy products like yogurt, milk, and cheese in the refrigerator?, Dated [DATE], accessed at this link: https://ask.usda.gov/s/article/How-long-can-you-keep-dairy-products-like-yogurt-milk-and-cheese-in-the-refrigerator, revealed: Milk can be refrigerated seven days. Review of Food and Drug Administration (FDA), Food Code, dated ,d+[DATE]/ 23, accessed at this link: https://www.fda.gov/food/retail-food-protection/fda-food-code, revealed: . Limitation of Growth of Organisms of Public Health Concern . Commercially prepared food . (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES. (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.

Based 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. Findings: During an observation on 9/11/24 at 9:17 AM, CNAs #1 and #2 performed Resident care to Resident #20. The CNAs were wearing gloves. CNA #1 wiped Resident's face with a wet washcloth followed by a dry washcloth. CNA #2 wiped the Resident's left arm and armpit with a wet washcloth followed by a dry washcloth. Then, CNA #2 while still wearing the same gloves, applied lotion to the Resident's left arm and sprayed deodorant onto the resident's armpit. On the other side of the bed, CNA #1 did the same to resident's right arm. During the same observation, CNA #2 cleaned Resident #20's perineal area (private parts) with a wet washcloth followed by a dry washcloth. Then, he/she rolled up the soiled brief. While wearing the same soiled gloves, CNA #2 held the Resident's right leg and arm and turned towards CNA #2. CNA #2 removed the soiled gloves and without performing hand hygiene, he/she put on new gloves. The same observation, revealed CNA #1 removed Resident #20's foam dressing in the buttocks, checked the Resident's skin, cleaned the Resident's buttocks and anal area with a wet washcloth, and then handed the soiled wet washcloth to CNA #2. CNA #2 put away the soiled washcloth in the laundry bag while continuing to hold the Resident's leg. CNA #1 stated We will rinse you . [Resident's name]. CNA #1 wiped the Resident's buttocks and anal area with a saturated wet washcloth and then handed the soiled washcloth to CNA #2. CNA #2 put away the soiled washcloth into the laundry bag and after this, while wearing the soiled gloves, he/she continued to hold the Resident's leg and arm. During the same observation, CNA #1 rolled up the soiled brief and wiped the Resident's buttocks with a dry washcloth. While wearing the same soiled gloves, CNA #1 put a new brief on the Resident. Then both CNAs dressed the Resident in his/her pants and shirt. After this, the CNAs placed the Hoyer lift (a mechanical lift device) sling under the Resident. While wearing the same soiled gloves, CNA #2 placed the wheelchair next to the bed and placed a pillow and a pad onto the wheelchair and then transferred the Resident with the Hoyer Lift into the wheelchair. CNA #1 removed all the soiled linens and pillowcases. CNA #1 removed the soiled gloves and without performing hand hygiene, CNA #1 put on new gloves. During an interview on 9/12/24 at 2:02 PM, the Infection Preventionist stated the CNAs were trained on hand hygiene during caregiver orientation, during skills fair, and annually. Review of the facility's Hand Hygiene Policy, dated 9/2019, revealed: .Gloves.hand hygiene should be practiced immediately after removal of gloves.Indications for Hand Hygiene, hand hygiene will be performed before and after the following activities.after taking off gloves. if moving between contaminated body sites to another body site during care of the same patient. Review of Centers for Disease Control and Prevention (CDC), Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, accessed at this link: https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, revealed: . Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Always clean your hands after removing gloves.

Based 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. Findings: During resident group interviews conducted on 3/01/23 from 1:06 PM-2:10 PM, the Residents at Lodge #1 were asked if they knew how to contact the long-term care ombudsman or the state agency. Resident #'s 19, 22, and 29 stated they did not know how to file a grievance with the facility or contact the state agency. Resident #s 19 and 22 stated they did not know how to contact the long-term care ombudsman's office. Observations on 2/27/23-3/3/23 revealed no signage in Lodge #1 that contained the phone numbers and addresses of the State Survey Agency, the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, the Medicaid Fraud Control Unit; and the Office of Civil Rights.

Based 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. Findings: Food storage: Lodge #1: An observation on 02/27/23 at 11:32 AM, of the refrigerator located in the pantry, revealed: - Unfrozen package of ground meat in zip lock bag on bottom shelf, writing on label [Lodge #1] not dated; - Unfrozen package of ground meat in zip lock bag on bottom shelf, writing on label [Lodge #2] undated; - One container of Liquid Whole Eggs opened: no opened date. Dry Storage located in the pantry: - One container of Potato Pearls opened, and resealed, no open date; - One Krusteaz Cornbread box opened and resealed, no open date. Lodge #2: An observation on 02/27/23 at 11:46 AM of the kitchen and pantry revealed: The refrigerator located in the pantry: - One zip lock bag of chowder with no opened date. The freezer located in the pantry: - Frozen opened bag of cookies with no opened date; - Frozen opened package of ravioli with no opened date; - Frozen opened packaged of stew with no opened date. Further observation revealed several inches of dried dark red debris which had formed a drip line ending in a palm sized circular splatter pattern down the back of the freezer bottom. Frozen food packages were placed in front of this debris. During an interview on 02/27/23 at 11:22 AM, Cook #1 in Lodge 1 stated that opened food items needed to be resealed and dated. Review on 03/02/23 of the facility's policy Food Receiving & Storage, dated 01/2023, revealed Maintain clean food stage areas at all times. Review on 03/02/23 of the facility's policy Refrigerators/Freezers, dated 11/2022, revealed Clean, keep free of debris, and mop the refrigerators & freezers with sanitizing solution regularly. During an interview on 02/27/23 at 11:48 AM, when asked how the facility knew when an open item needed to be discarded, Cook #2 in Lodge 2 stated opened food items needed to be dated with a throw away date. During an interview on 03/01/22 at 3:53 PM, the Dietary Manager stated opened foods should have been labeled and dated. Review on 03/02/23 of the facility's policy Food Receiving & Storage, dated 1/2023, revealed Cover label & date foods that have been cut/sliced/opened with opened on and use by date, and Open containers must be dated and sealed or covered during storage. Safe food preparation practices: During an observation in Lodge #2 on 3/02/23 at 10:51 AM, Cook #3 was observed plating lunch for the residents. After removing a plastic container of cheesy eggs out of the warming drawer and set on the counter, the Cook retrieved 5 plates and set them on the counter. While wearing the same gloves, he/she placed the buns on the plates and used the same right gloved hand to remove the top bun. Cook #3 then picked up a bottle of mayonnaise with a right gloved hand and while squirting the mayonnaise on the buns, touched the buns with the tip of the container. The Cook then picked up 2 potholders and removed a foil covered metal pan from the oven and set it on the counter. Cook #3 put the potholders on the counter and picked up a spatula and used it to remove tuna patties from the pan, placing them on the open buns. Without performing hand hygiene and changing gloves, Cook #3 used his/her right hand to place the top buns on the sandwiches. Review on 03/02/23 of the facility's policy PSMH [Providence [NAME] Mountain Haven] Food Preparation & Service, dated 11/2022, revealed the Cooks were to, Adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness, and Change Gloves & wash hands when changing tasks. Review of The Food Code, U.S. Public Health Service 2022, accessed from https://www.fda.gov/media/164194/download, revealed: 1. Code of Federal Regulations, 2-301.14 When to Wash. (e) After handling soiled equipment or utensils; (f) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks

Based 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. Findings: Record review on 2/28/23-3/2/23 revealed Resident #9 had diagnoses that included a history of dementia, osteoporosis (bone disease that causes a decrease in bone strength), and arthritis. Review of Past Medical/Surgical History, dated 7/11/22, revealed the Resident had suffered a ground-level fall . found to have minimally displaced fracture of medial malleolus [foot end of the leg bone] of the right ankle and a nondisplaced fracture of acromion [shoulder blade] of left shoulder .also had a contusion to left chest wall. Review the most recent Minimum Data Set (MDS- a federally required assessment), a quarterly assessment, dated 2/10/23, revealed the Resident was coded P0200. Alarms. An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. A. Bed alarm. 2=Used daily. B. Chair alarm. 2=Used daily. D. Motion sensor alarm. 2 = Used daily. Review of Resident #9's Care Plan, dated 2/15/23, revealed Need/Preference .I: have the potential to fall down and hurt myself .Because I: have dementia and osteoporosis .Approach .I need my nurses to .Keep an eye on my behaviors. I need my aids to . keep my bed low to the ground and keep the wheels locked, frequently check on me and make sure important night items are in my reach. After my last fall I need assistance to reposition and transfer .I need everyone to .Report changes in my abilities to my nurse. Know that I had a fractured right ankle and left shoulder. My bed and chair alarm are in place .Goal .My Goal is to: stay safe while I'm moving about and avoid injury. Goal time: 3 months. During an observation on 2/27/23 at 12:14 PM, Resident #9 was eating a snack while seated in a Geri-chair (a specialized upholstered recliner with a wheeled base) at the dining room table. After finishing the snack, the Resident propelled back to his/her room by sitting on the edge of the chair and using both feet to shuffle along the floor. A magnetic fall alarm was attached to the Resident's chair with the end of the pull cord clipped to the back of the Resident's pajama top. During a second observation on 2/28/23 at 8:47 AM, Certified Nursing Assistant (CNA) #4 was assisting Resident #9 with morning cares. The Resident, seated in a Geri-chair, propelled him/herself out of the room and into the common area of the lodge. Continuous observation on 2/28/23 from 8:55 AM until 9:34 AM revealed the Resident's magnetic clip was not attached to his/her clothing and was observed hanging down the back and behind the cushion of the Geri-chair. During an interview on 2/28/23 at 9:34 AM, Licensed Nurse (LN) #4 was asked about the Resident's magnetic alarm. The LN replied it was supposed to be clipped to the Resident's clothing, while stating the Resident sometimes unclipped it. Review of the facility's policy .Comprehensive Assessment & Care Plan, dated 5/2022, revealed Lodge Nurse .Implements Care Plan and Daily Care Standards consistently.

Based 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. Findings: Record review from 2/27/23-3/3/23 revealed Resident #33 was admitted to the facility with diagnoses that included stroke, renal (kidney) failure and pneumonia. During an interview on 2/28/23 at 11:02 AM, Resident #33 stated he/she had been unable to walk since he/she returned from the hospital. The Resident further stated his/her leg was hurting but his/her pain level was better now. Resident #33 stated he/she had been asking staff if he/she could start getting his/her legs going again. The Resident further stated staff hadn't helped him/her with mobility yet and he/she was afraid of the mechanical lift staff used to assist him/her out of bed. Record review of Resident #33's most recent MDS (Minimum Data Set, a federally required nursing assessment), a significant change MDS, dated [DATE], revealed under Walk in room . and Walk in corridor ., neither activity occurred during the look back period (assessment that looked back for 7 days). Review of the facility's policy, .Comprehensive Assessment & Care Plan, dated 5/2022, revealed The care plan is revised as changes occur and is also reviewed and revised, as needed, after completion of any assessments required by the RAI [Resident Assessment Instrument] including quarterly, annual and Significant Change in Status (SCSA) MDS. Review of Resident #33's Care Plan, dated 1/31/23, revealed: using my platform 4 wheeled walker either independently or with supervision, as I prefer. I also use my wheelchair for mobility and can tell you which I would prefer to use. During an interview on 3/1/23 at 3:04 PM, Certified Nursing Assistant (CNA) #2 stated Resident #33's goal was to get up and walk again but the Resident had declined in mobility. The CNA further stated 2-3 weeks ago, the Resident required a Hoyer lift device to get out of bed, but the Resident had been walking not too long ago. The CNA further stated Resident #33 had a contracture (formed due to inactivity of the affected body part) of his/her leg and he/she had placed a pillow to support the Resident's leg. During an interview on 3/2/23 at 12:50 PM, Licensed Nurse (LN) #1 stated Resident #33 was unable to walk. When asked the process if a resident was declining, the LN stated he/she would have reported to the Restorative Aide if a resident was no longer walking. During an interview on 3/2/23 at 3:55 PM, the MDS Coordinator stated she performed a significant change assessment for weight loss for Resident #33 after he/she returned from the hospital. When asked if she was aware Resident # 33 was unable to walk, the MDS Coordinator stated she was aware the resident was unable to walk when the resident had nausea during her illness. The MDS Coordinator further stated she felt like Resident #33 would improve and hadn't heard the resident had problems with mobility. The MDS Coordinator stated the facility could probably have added ROM (Range of Motion) exercise to the Resident's restorative plan. During an interview on 3/2/23 at 5:14 PM, the Physical Therapist (PT) stated she was not aware Resident #33 was unable to walk. When asked the process to preserve mobility if a resident was no longer able to walk, the PT stated a screening would have been performed. Further review of the facility's policy, .Comprehensive Assessment & Care Plan, dated 5/2022, revealed the MDS Coordinator or Designee Reviews any care plan changes or recommendation for changes to ensure that approaches are aligned with comprehensive assessment, resident preferences, needs, goals, and professional standards or practice. The LN Reviews resident Care Plans and keeps team informed of changes .Implements Care Plan and Daily Care Standards consistently. The Clinical Support Team Revises Care Plan in response to immediate needs or changes in condition by: a. Making an addition to the Care Plan in the electronic health record. B. Notifying the RN [Registered Nurse] Team Advisor or MDS Coordinator of Care Plan changes .[and] Evaluated the effectiveness of care plan approaches.

Based 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. Findings: Resident #9: Record review on 2/28/23-3/2/23 revealed Resident #9 had diagnoses that included dementia and depression, and macular degeneration (progressive disease that causes visual impairment). During a continuous observation on 2/27/23 at 12:30 PM-1:15 PM, Resident #9 was observed seated in a Geri-chair eating at the table in the dining room. After completing the meal, the Resident used his/her feet to propel back to his/her room. Cartoons were observed playing on the television while the Resident was in their room. During an observation on 2/28/23 at 8:47 AM, Certified Nursing Assistant (CNA) #4 was observed assisting Resident #9 with morning cares, the Resident was seated in a Geri-chair combing his/her hair. The television was turned on and playing the cartoon Paw Patrol. During an interview on 2/28/23 at 9:00 AM, the CNA stated they consulted the care plan to provide care to the Resident. When asked what type of activity interventions the Resident enjoyed, CNA #4 replied the Resident enjoyed going to Bingo in the other lodges. The CNA stated he/she had not been here when the Resident engaged in any activities, adding if they cannot coax the Resident into an activity, the Resident became depressed and tearful. Review of Resident #9's care plan, dated 2/15/23 revealed: I: Have the potential to experience social isolation and low activity participation .Because I: [have] cognitive deficit anxiety, depression, [and] don't see very well, and [I'm] often bored, have a hard time getting around, often hurt .In the past: I enjoyed reading mystery and [NAME] King books. I will listen to people read aloud; However, do not choose to read myself I Need everyone to: .encourage religious programs and know I identify as Christian with no particular sect .know I enjoy watching mysteries, The Voice, and American [NAME], assist as needed. According to my family, I 'despise' Cartoons. Review of Life Engagements, revealed the last documented activity occurred on 2/21/23 at 1:27 PM. Observation of Resident #9 on 3/02/23 from 10:30 AM-10:55 AM revealed Resident #9 was seated in the Geri-chair with both feet up on the bed. The television was turned off and the Resident was sitting in the room staring out the window. Resident #37: Record review on 2/28/23-3/2/23 revealed Resident #37, admitted in January of 2023, had diagnoses that included dementia following a stroke, pressure wounds, and contractures (flexed immobility of extremities), dysphagia (difficulty swallowing), and difficulty communicating. Random observations on 2/28/23 from 1:00 PM-2:00 PM revealed Resident #37 spent the day in bed. The television was turned on and the Resident had a stuffed animal in bed with him/her. During an observation on 3/1/23 from 9:50 AM-11:18 AM, Resident #37 was observed in bed. A western movie was playing on the television, no other activities were observed. During an interview on 3/1/23 at 10:00 AM, Licensed Nurse (LN) #4 stated due to his/her pressure wound, Resident #37 was unable to sit up for prolonged periods of time. The LN stated Resident #37 always had a western on television. The LN also stated the Resident used to be a flamingo [NAME]. Review of Resident #37's Life Engagements-Functional Assessment [used to determine activity goals], undated, revealed no documented assessment of the Resident's preferred activities. Review on 3/1/23 of the Resident's Care Plan, dated 2/3/23, revealed I Have: Not had much interest in doing things Because I: Moved here recently and feel tired or sleep a lot, may want to engage you in conversation .I need my aides to .encourage me to participate in activities .My Goal Is To: feel safe and secure. Review of Life Engagements, where staff documented activity interventions, revealed the only documented activity since admission was on 2/21/23 at 1:27 PM was LIFE ENGAGEMENTS: other: table floral arrangements PARTICIPATION: active observed. During an interview on 3/2/23 at 9:42 AM, the Director of Nursing (DON) stated she and the Nurse Manager had been overseeing the activities program. The DON stated the Activities Coordinator was currently off work until May. During an interview on 3/3/23 at 10:35 AM, when asked how the residents received activities, CNA #3 stated they were supposed to be helping with activities but were just too busy providing resident care. CNA #3 stated it was difficult to find time when the nurse was working between 2 cottages. The CNA stated this Lodge was difficult because some of the residents did not come out of their room, so the activities needed to be individualized or one-to-one. Review of the Activity Schedule for the week of 2/27/23-3/3/23 revealed on 3/2/23 Karaoke was listed as an activity, but there was no time listed next to the event. During an interview on 3/3/23 at 11:00 AM, when asked if the cottage had the scheduled Karaoke yesterday, Resident #22 stated no they had just colored. The Resident stated Karaoke would have been more fun than coloring because it was funny. During an interview on 3/03/23 at 11:20 AM, the DON stated she and the Minimum Data Set Nurse were the only ones that could have covered activities in the lodges today. Review of the facility website, accessed on 3/15/23, at https://www.providence.org/locations/ak/[NAME]-mountain-haven#tabcontent-1-pane-5 revealed: Activity therapies .Here at Providence [NAME] Mountain Haven, we have dedicated staff that provide opportunities for the elders to enjoy the highest possible quality of life through meaningful activity. The programs consist of large group, small group, one to one and individual activities that meet the needs of individual residents. Our therapists complete an assessment of each resident, provide materials or other means of interest for meaningful activity pursuits. We also implement individualized activity care plans and activity calendars. Some activities include painting, arts & crafts, karaoke, bingo, card games, movies, reading, special entertainment and holiday events. Community outings, such as shopping, going to lunch, going to movies, trips to the fair and scenic drives are strong components of the program. Families can be included in the activity planning process and our therapists promote good mental health by encouraging and assisting residents to socialize with each other and maintain contact with family and friends. Review of the policy Documentation, Life Enhancement, revised 5/2022, revealed 1. Life Enhancement/Engagement staff will meet with resident and family, as appropriate, within 7 days of admission to determine what activities are preferred and what adaptations are needed. Chart review will be accomplished, and an assessment will be completed then documented within the Electronic Health Record. 2. Assessments will be documented with each quarterly, annually and/or with any significant change review. 3. Goals will be documented following the assessment. 4. Assessment will be determined by needs of residents. Care Plan-Life Enhancement/Engagement Care Plan will be created based on assessment and Resident needs/requests: Care plan will be reviewed and updated as indicated quarterly, annually and with any significant change. General Documentation: Documentation will be input into the Electronic Health Record for each resident individually or as part of a group as indicated. Attendance to group gatherings will be recorded. Notations will be input directly to those approaches that are currently used to meet the goals set for each resident. Additionally, activities the resident participates in may be input in areas such as social services and nursing services as indicated within their areas of practice and notation via Electronic Health Record. Significant resident response will be reported to Interdisciplinary Team and adaptations as indicated will be addressed within the care plan as needed.

Based 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. Findings: Resident #18: Left hand device: Record review from 2/27/23-3/3/23 revealed Resident #18 was admitted to the facility with diagnoses which included stroke, left sided hemiplegia (weakness on one side of the body) and depression. During an observation and interview on 2/28/23 at 12:47 PM, when asked if he/she was receiving rehabilitation (rehab) services, Resident #18 stated he/she has had physical declines. An observation revealed the Resident's left hand was contracted (shortening of the tendons which puts the digits in a fixed position) in a closed position. The Resident was unable to open his/her left hand. During the observation an unpleasant odor was eminating from Resident's closed hand. During a follow-up interview on 2/28/23 at 1:31 PM, Resident #18 stated he/she was not receiving ROM exercises. The Resident further stated he/she wanted to exercise, but stated staff told him/her that he/she needed to do the exercises staff taught him/her on his/her own. The Resident further stated he/she wanted to get back (physically) to where he/she was. During an observation on 3/1/23 at 10:01 AM, Resident #18 was lying in bed on his/her back, with his/her torso leaning towards the left side, which was partially covering the Resident's left hand. No device was observed in the Resident's contracted palm. During an interview on 3/1/23 at 10:15 AM, CNA #1 stated the CNAs were responsible for performing ROM exercises for the residents and he/she used the Resident's care plan for guidance on which exercises to perform. The CNA further stated the exercises were documented under restorative care in the electronic health record (EHR). When asked about Resident #18's left hand exercises and devices, CNA #1 stated Resident #18 did not have any devices for his/her left hand. The CNA further stated he/she did not perform any exercises for the Resident's left hand or arm, as he/she was not given any instructions or shown any exercises to utilize for the Resident. Review of Resident #18's Care Plan, dated 2/27/23, revealed: follow my restorative plan . During a follow up interview on 3/1/23 at 2:19 PM, when asked to review Resident #18's restorative plan in the EHR, CNA #1 reviewed the restorative documentation and stated there was an area to chart device usage, but the Resident did not have a device. Record review of Resident #18's Restorative Care notes, dated 11/18/22 at 5:55 PM, revealed: Comfy Air Hand Roll .Deflate splint prior to positioning in palm of left hand .straps are securing splint in place to facilitate digit extension 8 hours (during awake hours) .2X [times]/day every day . [for] Contraction prevention, decrease flexion tone in left digits, comfort, joint integrity . Review of the Restorative Care notes, dated 11/19/22- 11/30/22 revealed documentation the splint device was: - on for 15 minutes on 11/19/22; - on for 15 minutes on 11/27/22; - on for 15 minutes on 11/29/22; - on for 15 minutes on 11/30/22. Review of the Restorative Care notes, dated 12/1/22- 12/31/22 revealed documentation the splint device was: - on for 15 minutes on 12/1/22; - on for 15 minutes on 12/2/22; - on for 15 minutes on 12/4/22; - on for 15 minutes on 12/7/22; - on for 15 minutes on 12/12/22; - on for 15 minutes on 12/22/22; - on for 15 minutes on 12/24/22; - on for 15 minutes on 12/29/22; - on for 15 minutes on 12/31/22. - Review of the Restorative Care notes, dated 1/1/23- 1/31/23 revealed documentation the splint device was: - on for 15 minutes on 1/11/23; - on for 15 minutes on 1/12/23; - on for 15 minutes on 1/13/23; - on for 0 minutes on 1/14/23 due to resident refusal; - on for 15 minutes on 1/19/23; - on for 15 minutes on 1/20/23; - on for 15 minutes on 1/25/23; Review of the Restorative Care notes, dated 2/1/23- 3/1/23 revealed documentation the splint device was: - on for 15 minutes on 2/4/23; - on for 15 minutes on 2/10/23; - off for 0 minutes on 2/16/23; During an interview on 3/2/23 at 12:50 PM, Licensed Nurse (LN) #1 stated he/she did not know if Resident #18 used a device for his/her left hand. The LN entered the Resident's room to search for the device. The LN then stated he/she found the device on the windowsill and asked the CNA to put the device on the Resident's hand. When asked how licensed staff ensured the Residents' received ROM, LN #1 stated he/she would have followed up with the CNAs. The LN further stated most of the time the CNAs would have alerted the nurses if a resident had refused ROM. During an interview on 3/2/23 at 3:40 PM, the Occupational Therapy (OT) Assistant #1 stated Resident #18 had tried multiple devices and was now using a hand roll. The OT Assistant further stated the Resident also had passive ROM exercises for his/her left hand on the restorative plan. Heel-Cord exercises: Further review of the Resident #18's Restorative Care notes, dated 9/1/22 at 9:24 AM, revealed: RESTORATIVE-PASSIVE RANGE OF MOTION LOWER: Hip and knee flexion Hip abduction Ankle rotation Heel-cord stretching .1X/day AM 3X/[week] Monday Wednesday Friday .LOWER extremity left side .calf stretching for contracture prevention . During an interview on 3/1/23 at 4:13 PM, when asked what heel-cord stretching was, CNA #1 stated the heel- cord stretch was an exercise done with a band. Review of the Restorative Care notes, dated 11/17/22- 3/1/23, revealed documentation of Active ROM Heel-cord stretching for 5 minutes on 11/23/22. Further review revealed no further documentation of Heel-cord stretching. During an interview on 3/2/23 at 5:14 PM, when asked what heel-cord stretching was, the Physical Therapist (PT) stated it was moving the foot with a toes up position. Resident #33: Record review from 2/27/23-3/3/23 revealed Resident #33 was admitted to the facility with diagnoses that included stroke, renal (kidney) failure and pneumonia. During an interview on 2/28/23 at 11:02 AM, Resident #33 stated he/she had been asking staff if he/she could start getting his/her legs going again. The Resident further stated staff hadn't helped him/her with mobility yet. Record review of Resident #33's significant change MDS (Minimum Data Set, a federally required nursing assessment), dated 10/21/23, revealed under Walk in room . and Walk in corridor ., the Resident required Supervision-oversight, encouragement or cueing for both activities. Review of Resident #33's Restorative Care notes, dated 11/2/22 at 1:00 PM, revealed: Walk minimum of 25 feet .Walker .assist of 1 [person] .3 [times per week] .To maintain safe ability to ambulate distances. Review of Resident #33's Restorative Care notes, revealed from 11/2/22-11/30/22: -On 11/2/22- the Resident decline to participate; reported to Restorative Nurse; -On 11/9/22- the Resident decline to participate; reported to Restorative Nurse; -On 11/16/22- the Resident decline to participate; reported to Restorative Nurse; -On 11/18/22- the Resident decline to participate; reported to Restorative Nurse; and -On 11/30/22- the Resident decline to participate; reported to Restorative Nurse. Further review revealed no documentation of restorative walking for the months of December 2022 or January 2023 (Resident was out of the facility and hospitalized for approximately 7 days in January 2023). Record review of Resident #33's most recent MDS, a significant change MDS, dated [DATE], revealed under Walk in room . and Walk in corridor ., neither activity occurred during the look back period (assessment that looked back for 7 days). Review of Resident #33's Care Plan, dated 1/31/23, revealed: using my platform 4 wheeled walker either independently or with supervision, as I prefer. I also use my wheelchair for mobility and can tell you which I would prefer to use. Review of Resident #33's Restorative Care notes for the month of February 2023 revealed: -On 2/3/23- The Resident was unable, declined walking; -On 2/6/23- The Resident decline to participate- reported to the Restorative Nurse; -On 2/8/23- The Resident declined to participate- reported to Restorative Nurse (resident unable to walk); -On 2/10/23- the resident was unavailable; and - On 2/17/23- the Resident declined walking. During an interview on 3/1/23 at 3:04 PM, CNA #2 stated Resident #33's goal was to get up and walk again but the Resident had declined in mobility. The CNA further stated 2-3 weeks ago, the Resident required a Hoyer lift device to get out of bed, but the Resident had been walking not too long ago. The CNA stated Resident #33 had a contracture of his/her leg and he/she had placed a pillow to support the Resident's leg. When asked how he/she knew the restorative exercises the Resident required, CNA #2 stated he/she was trained by CNA #3 on how to move the Resident in bed because the Resident was frail. The CNA further stated CNA #3 taught him/her how to move the resident's leg without hurting him/her and provide a little ROM to the Resident as he/she tolerated. During an interview on 3/2/23 at 12:50 PM, Licensed Nurse (LN) #1 stated Resident #33 was unable to walk. When asked if the Resident received restorative care, the LN stated he/she could not recall. During an interview on 3/2/23 at 5:14 PM, the Physical Therapist (PT) stated she was not aware Resident #33 was unable to walk. When asked the process to preserve mobility if a resident was no longer able to walk, the PT stated a screening would have been performed. Review of the facility's policy .Nursing Restorative Program, dated 3/2021, revealed: .the facility will provide the Residents a Restorative Nursing program for maintaining physical functioning abilities and range of motion according to plans of care written by therapy and nursing professionals.

Based 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. Findings: Random observations throughout the survey on 2/27/23-3/3/23 revealed the most recent survey results were located on the counter near the residents dining tables in all 4 Lodges (#s 1, 2, 3, and 4). A sign posted nearby revealed Survey Report binder is located on the counter in the dining area accessible to Elders and their families at all times. Further observation revealed the binder, labeled Survey Results was bolted to the wall with an approximately 18-inch-long cable. Review of the binder's content revealed the most recent survey results. Further review revealed no prominent posting that indicated 3 years of survey results were available for the residents or their representatives to review. During an interview on 3/03/23 at 10:30 AM, the Quality Director stated she was not aware signage was required to be posted that notified the residents that 3 years of survey results were available for their review per request.

Based 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. Findings: Review of the facility policy titled, Psychopharmacological Drug Use and Gradual Dose Reduction, revised 3/2021, showed, .Antipsychotic medications: lf the attending physician or prescribing practitioner wishes to write a new order for a PRN antipsychotic the attending physician or prescribing practitioner must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. The required evaluation entails the attending physician or prescribing practitioner to directly examine the resident and assess the resident's current condition and progress to determine if a PRN antipsychotic medication is still needed. As part of the evaluation, the attending physician or prescribing practitioner should al a minimum determine and document the following in the resident's medical record: is the antipsychotic medication still needed on a PRN basis? What is the benefit of the medication to the resident? Have the resident's expressions or indications of distress improved as a result of the PRN medication? The PRN order cannot exceed 14 days . In addition, the facility policy showed, . Anti-anxiety, sedative. hypnotics, and antidepressant medications: initial PRN orders are valid for 14 days. The medications may be reordered for up to 60 days with appropriate documentation supporting the need for continuing the medication . 1. Per the Patient Information sheet located in the Face Sheet tab of the electronic medical record (EMR), Resident #26 was admitted to the facility on [DATE] with diagnoses of dementia, major depressive disorder, and anxiety disorder. Review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/7/21, located in the MDS tab of the EMR, revealed Resident #26 was administered an antipsychotic and an antianxiety medication daily during the assessment period. Review of the Physician Orders located in the Physician Orders tab of the EMR, revealed the physician had prescribed [MEDICATION(S)] (an antipsychotic medication) 0.5 milligrams (mg) everyday, PRN for agitation, hallucinations, or other distressing delusions on 10/15/21. Review of this order showed the physician had reordered the [MEDICATION(S)] on 11/8/21 however, the order did not contain a 14-day Stop Date or physician assessment with documentation to include the need to continue the medication, as required. In addition, the Physician Orders revealed on 10/15/21, the physician had written an order for [MEDICATION(S)] ([CONDITION(S)] medication) 0.5 mg three times daily, PRN for anxiety. Review of this order showed the physician had reordered the [MEDICATION(S)] on 11/8/21 however, the order did not contain a Stop Date not to exceed 60 days, as required. 2. Per the Patient Information sheet located in the Face Sheet tab of the EMR, Resident #28 was admitted to the facility on [DATE] with diagnoses of stroke and anxiety disorder. Review of the Physician Orders found in the EMR under the orders tab showed that on 10/22/21, Resident #28 was prescribed Lorazepam (an anti-anxiety medication) 1 mg at bedtime PRN for anxiety. The order did not contain a Stop Date not to exceed 60 days, as required. In an interview on 11/12/21 at 2:41 PM, the Medical Director stated that he/she was not aware of the policy of the 14-day Stop Date, or physician assessment, as required for the antipsychotic medication or the need for a Stop Date on the [CONDITION(S)] medication. In an interview on 11/12/21 at 3:56 PM, the Pharmacist stated he/she was not aware of the regulation or the facility policy regarding PRN use of antipsychotic and [CONDITION(S)] medications. 3. Review of Resident #6's EMR under the Face Sheet tab revealed a Patient Information document indicating the Resident was admitted to the facility on [DATE] with diagnoses of anxiety disorder, acquired absence of left leg below the knee, and major depressive disorder. Review of Resident #6's EMR under the Physician Orders tab revealed an order dated 8/10/21 for Lorazepam 1 mg (milligram) po (oral) q (every) four hours PRN for agitation. Another physician's order dated 8/13/21 revealed an order for [MEDICATION(S)] (anti-psychotic) 5 mg, po daily, PRN for agitation, give another dose if the first dose is inefficient. There was no evidence located in the EMR either of the medications had a stop date. Review of Resident #6's EMR under the MAR (Medication Administration Record/TAR (Treatment Administration Record) tab for September 2021 it was documented the Resident was administered Lorazepam 22 days and [MEDICATION(S)] 18 days. Review of the MAR for October 2021 it was documented the Resident was administered Lorazepam 25 days and [MEDICATION(S)] 15 days. Review of the MAR for November 2021 it was documented the Resident received Lorazepam eight days and [MEDICATION(S)] four days. During an interview on 11/12/21 at 2:42 PM, the Medical Director revealed he was not aware PRN antipsychotic medications required a stop date of 14 days, unless a physical assessment was completed to include the rationale for the continuation of the medication. The Medical Director confirmed Resident #6 had orders for Lorazepam and [MEDICATION(S)] with no stop date and the Resident was still currently receiving the medications. During an interview on 11/12/21 at 4:00 PM, the Pharmacist stated he/she was not aware PRN antipsychotic medications required a stop date of 14 days, or that he/she was responsible for notifying the physician about the PRN order.

Based 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. Findings: Review of Resident #91's Patient Information located in the Electronic Medical Record (EMR) under the Face Sheet tab indicated the Resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Intake Information provided by the facility revealed on 2/16/21 Resident #91 had stated the night shift had pulled on her/his arm. Review of the Final Report of the investigation dated 2/17/21 revealed the investigation did not include all the names and dates of staff interviewed. The Final Report did not have interviews with other residents to determine if there were any other concerns related to staff to resident abuse. The final conclusion was no abuse occurred. During an interview on 11/12/21 at 10:00 AM, the Assistant Director of Nursing (ADON) stated she/he was not aware of having to talk to other residents and the investigation provided was all she/he had. Review of the facility policy titled, Abuse Protection and Prevention revised 3/2021 revealed there would be complete evidence that all alleged violations were thoroughly investigated.

Based 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. Findings: Per a facility policy titled, Comprehensive Assessment and Care Plan, revised 03/2021, revealed, .Care plan changes or recommendations for changes to ensure that approaches are aligned with comprehensive assessment, resident preferences, needs, goals, and professional standards or practice . According to the Patient Information sheet located in the Face Sheet tab of the Electronic Medical Record (EMR), showed Resident #13 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Per the admission Minimum Data Set: (MDS), with an Assessment Reference Date (ARD) of 8/26/21, Resident #13 was assessed by staff to be moderately impaired in cognition. In addition, the assessment showed that he/she had multiple falls prior to admission and had sustained one non-injury fall and one injury fall during the seven-day assessment period. A Care Plan located in the Care Plan tab of the EMR, dated 9/8/21 showed a Focus fall care plan which stated that the Resident had the potential to fall down and hurt himself/herself or lose his/her balance and stumble. In addition, he/she has [CONDITION(S)] and has fallen. The approaches listed on the Care Plan were he/she needed the nurses to use an alarm on his/her bed to help remind him/her that he/she needs help to get up, keep his/her bed in the low position and locked, and to place a floor mat beneath his/her bed in case he/she rolls out. A review of three fall investigations Final Report, one dated 9/7/21, one dated 10/14/21 and one dated 11/01/21 provided by the facility, revealed Resident #13 had sustained three falls from 9/7/21 to 11/1/21. Two of the falls, on 9/7/21 and 11/1/21, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility fall investigation Final Report, dated 11/4/21 at 5:00 PM, revealed new interventions which included: Staff to were to sit with the Resident and allow one-to-one observation, as available. In addition, a helmet (which had been ordered) to protect his/her head from further injury, and to keep Resident #13 in sight as much as possible. The Care Plan did not show the updates/revisions listed in the fall investigation Final Report, nor were the falls documented to determine a pattern and if the interventions on the care plan were still applicable. In an interview on 11/12/21 at 10:55 AM Minimum Data Set Coordinator (MDSC) stated she/he was responsible for the nursing sections of the MDS. She/He stated the care plans were updated every three months. She/He confirmed she/he was not doing updates on the care plan until the next assessment and the interventions listed in the fall investigation Final Report for Resident #13 were not updated to his/her Care Plan.

Based 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). Findings: 1. According to the Patient Information sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed Resident #36 was admitted to the facility on [DATE] with a diagnosis of late onset Alzheimer's disease. Review of a significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 7/20/21 revealed Resident #36 was moderately impaired in cognition. She/He further exhibited delusions and wandering which placed the Resident at significant risk. The assessment further revealed the Resident was independent with ambulation. Review of the facility's investigation titled, Final Report, provided by the facility dated 9/27/21 at 10:00 PM, revealed on 9/23/21 at approximately 9:30 PM, Registered Nurse Team Advisor (RNTA), documented he/she was notified Resident #36 had eloped out of the Lodge and was outside. The resident was able to say she/he was okay but was unable to get up after having fallen however, there was no injuries, bleeding or bruising noted. There were no documented witness statements from staff, or the Resident included in the investigation. There was no root cause analysis completed to gather data or to identify the factors leading up to the elopement. During an interview with the RNTA on 11/10/21 at 8:17 AM revealed he/she was in the parking lot of the Lodge when he/she received a call from the Director of Nursing (DON) that Resident #36 had eloped from the Lodge. The RNTA revealed when he/she arrived to where Resident #36 was found Certified Nurse Assistant (CNA) #3 and Licensed Practical Nurse (LPN) #4 was already there with the Resident. The RNTA confirmed he/she had not obtained any documented witness statements from staff or the Resident regarding the events that led up to Resident #36 eloping from the Lodge. He/She confirmed there was no root cause analysis completed after he/she finished his/her investigation and the investigation needed improvement. In an interview on 11/11/21 at 9:16 AM, CNA #2 revealed they now have another CNA from 9:00 AM to 9:00 PM to help supervise Resident #36 and she/he has not exited the building since the intervention was put into place. 2. According to the Patient Information sheet located in the Face Sheet tab of the EMR, showed Resident #13 was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)] disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements.) Per the admission MDS with an ARD of 8/26/21, Resident #13 was assessed by staff to be moderately impaired in cognition. The assessment showed the Resident had multiple falls prior to admission and had sustained one non-injury fall and one injury fall during the seven-day assessment period. Review of a 9/07/21 at 3:50 PM fall investigation Final Report provided by the facility, revealed Resident #13 had gotten out of bed unassisted and had ambulated to bathroom. He/She fell and hit his/her head on the toilet and received five lacerations that resulted in sutures. The Final Report summary provided by the facility showed the Resident was alert and at baseline, they would continue to monitor the lacerations until healed. The bed alarm was in use at the time of incident and was not working. A maintenance request was submitted to ensure the alarm was working properly. The report did not show any further documentation of root cause analysis, witness statements, or documentation that maintenance had fixed the bed alarm. Review of a facility investigation Final Report provided by the facility, showed that on 10/11/21 at 10:05 AM, Resident #13 rolled out of bed and was found face down on the fall mat by staff that were responding to his/her bed alarm. A summary statement on the Final Report showed the resident was impulsive, was alert and at baseline and denied any form of abuse. In addition, the conclusion was he/she had a history of falls and frequent hallucinations and was responding to his/her hallucinations. The bed alarm and chair alarm would be continued as well as frequent visual checks and keeping him/her in high visible areas when awake. The Final Report did not show documentation of root cause analysis, or an interview with the Resident, or any staff interviews regarding the resident's fall. Review of a facility investigation Final Report provided by the facility, dated 11/4/21 at 5:00 PM revealed on 11/1/21 at 10:30 AM, Resident #13 was in his/her bed, resting quietly with eyes closed. Staff heard a noise from the Resident's room and immediately went to check on him/her. The Resident had gotten out of bed unassisted and was observed trying to stand up and walk, after falling and hitting his/her head. He/She received a laceration to the back of his/her head that did not require sutures. The summary to the Final Report showed Resident #13 was alert and at baseline. Staff would continue to monitor the laceration until resolved. His/Her bed alarm was in use at the time of the incident and was not working due to low battery; batteries were replaced. As a result of the fall, opportunities had been offered to staff for overtime to sit with the Resident and allow one-to-one observation, a helmet has been ordered to protect his/her head from further injury, and staff was keeping resident in sight as much as possible. There was no documentation of a root cause analysis for the fall. There were no interviews from the Resident or staff regarding the fall. In an interview on 11/12/21 at 10:01 AM, the Assistant Director of Nursing (ADON) confirmed she/he completed the investigations of Resident #13's falls. The ADON confirmed the investigations were not complete and doing a root cause analysis was talked about, however it was not documented anywhere on the investigation reports. A facility policy titled, Fall Prevention and After-Fall Care, revised 03/2021, revealed, .Every fall is investigated with the goal of determining the root cause, reducing fall risk, and reducing the likelihood of injury .

Based 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®). Findings: Review of the CDC website titled, Pneumococcal Vaccine Recommendations revealed, . Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later . https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html Review of a facility policy titled, Influenza/Pneumococcal Vaccine, revised 4/2021, showed, . Pneumococcal vaccine is offered to residents aged 65. A second pneumococcal immunization may be given 1 year following the first pneumococcal immunization, unless medically contraindicated . Review of the Patient Information sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed Resident #18 was admitted to the facility on [DATE] and was [AGE] years of age at the time of admission. Review of the Immunizations tab in the EMR revealed Resident #18 had been administered the PCV13 vaccine on 6/16/18. There was no evidence Resident #18 was administered the PPSV23 one year later, as recommended. In an interview on 11/12/21 at 9:29 AM the Assistant Director of Nursing (ADON) confirmed Resident #18 had not received the PPSV 23 timely and was currently overdue.

Based on observation, interview, and record review, the facility failed to recognize that a resident had sustained a fracture and did not seek medical attention for 14 days after the event occurred for one resident (Resident #15) of 15 sampled residents. This delay resulted in harm of ongoing pain and distress until a [DIAGNOSES REDACTED]. Findings: Review of Resident #15's Face Sheet revealed he/she was admitted to the facility on [DATE]. Review of his/his/her [DIAGNOSES REDACTED]. Review of Resident #15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/25/19, revealed he/she was unable to participate in a cognitive assessment but was evaluated by staff as having severely impaired decision-making abilities, did not reject cares, required supervision for mobility on the unit using a walker, could not participate in a pain interview but displayed no non-verbal indicators of pain such as grimacing, moaning, guarding, or rubbing a specific body part. Review of Resident #15's Nursing Notes (NN) revealed: On 9/10/19 at 4:05 pm, . nonverbal. Lying in bed this am after waking up, bruise noted on and around right ankle. CNA told staff on 9/9 (9/9/20) about elder dragging his/his/her ankle while being moved in wheelchair, no bruising noted yesterday per CNA . The note did not document when Resident #15's physician was notified of the bruising or what the physician's response was. The note did not document when Resident #15's family was notified. 9/12/19 at 1:04 pm, . Targeted Moods/Behaviors: Screaming/Disruptive sounds slapping hands on legs/thighs this am . 9/13/19 at 3:30 am, . [MEDICATION NAME] HCl 5 mg tablet given for pain/discomfort restlessness, rubbing his/his/her leg, gnawing on his/her own fingers, agitated, wakeful . 9/14/19 at 12:55 am. Indicators or possible indicators of pain . repetitive behaviors, sticking fingers in his/her mouth, slapping at self, chewing on covers . 9/14/19 at 10:46 am, . Increased (signs and symptoms) of pain by elder, Elder will recoil with touch of (right) foot . Reported bruising of (right) ankle on 9/10. Bruising still present, no swelling noted. Assessment: Per SOAP (Subjective/Objective/Assessment/Plan) note and nursing observation. Elder's foot has been dragging while in wheelchair. Bruising was observed yesterday and again today. Appears to be decreasing. Plan: Will continue to monitor. Elder is on scheduled [MEDICATION NAME] for pain and has (as needed) medication available. Due to PT/OT not being available on the weekends, a draw sheet was tied across elder's wheelchair footrests to keep legs from dragging and off the ground. Educated CNAs to monitor . The note did not document when the resident's physician was notified or what the physician's response was. On 9/17/19 at 3:04 pm, . Mood/Behavior: Rejection of Care Kicking/Hitting. Intervention reassured, redirected, reoriented. Outcome: unchanged . On 9/18/19 at 10:16 pm, . [MEDICATION NAME] HCl 5 mg tablet given for pain/discomfort restlessness, slapping (at) his/his/her right leg, digging in mouth with fingers, chewing on bed covers, moaning at intervals . On 9/21/19 at 2:55 am, . Indicators or possible indicators of pain: repetitive behaviors, sticking fingers in his/her mouth, slapping (at) self, chewing on covers . On 9/23/19 at 12:05 am, . Mood/Behavior: Displayed anger with self and/or others, spitting out medication, throwing/smearing food/waste. Interventions: left alone and re-approached, redirected. Outcome: unchanged . On 9/24/19 at 7:34 pm, . (Nurse Practitioner) also looked at right ankle bruising that occurred from 9/9 when elder had his/her right foot caught under wheelchair per report. Bruising noted 9/10 (9/10/19) but has increased . bruising has spread to top of foot and up lower leg area . X-ray ordered after 7 pm . There was no copy in the medical record for x-ray results for Resident #15 or the physician's orders [REDACTED]. Review of Resident #15's Physician's Progress Notes, documented by the prior medical director, for 10/11/19 revealed, . 9/9/19: Elder had right foot caught under wheelchair . 9/24/19 . x-ray (right) ankle for right ankle pain, swelling, ecchymosis after fall (with) foot caught under wheelchair (with) result consistent (with) nondisplaced ankle fracture . 9/25/19: (Non-weight bearing to the right lower extremity). PT eval for splinting. Elevate (right lower extremity) while in bed X 14 days. Cool packs to (right) ankle and (every two hours as needed for) 7 days . 9/26/19: air cast over sock (right ankle) when (out of bed); skin checks to area daily . Review of Resident #15's care plan revealed a Need/Preference area on 1/23/20 of, . I can't complete cares on my own because I have [MEDICAL CONDITION]. I show this by not participating in my ADL's (Activities of Daily Living) and not understanding instructions . An approach of, . I move about the unit with the help of 1 person, I use a wheelchair with calf supports/pads . also dated 1/23/20. On 3/4/20 at 1:00 pm, the facility's Director of Quality (DOQ) provided a copy of Resident #15's care plan, and a printout of some of the changes that had been made to the resident's care plan since September 2019. The DOQ stated, Unfortunately, we are struggling with our system a little and it seems as though not all of the care plan changes are showing up. The care plan changes we have provided you are the only ones we could find, prior to the January 23 care plan. Review of the care plan updates provided revealed no care plan for his/her mobility or pain levels prior to the current care plan, or what care plan may have been in place at the time of the resident's injury. An interview with the Interim Director of Nursing (IDON) on 3/5/20 at 4:54 pm revealed he/she had just started working at the facility around the time Resident #15 fractured his/her ankle and had not been completely aware of the circumstances at the time. The IDON stated after he/she began working at the facility it became apparent that the nurse manger in charge of wound care and was responsible to report changes in status of the residents to facility leadership was either not documenting or falsifying documentation, so was terminated. The IDON stated that nurse would have been the person to whom the bruising was likely reported, and no record was made of what had been done to respond to the bruising. The IDON stated communication between the lodges and management was obviously still an issue. The IDON agreed that 14 days between the onset of bruising and the identification of a fracture was too long. An interview with the DOQ on 3/5/20 at 5:15 pm revealed facility leadership had been unaware of Resident #15's fracture until it was called to their attention by the surveyors. The DOQ stated, We didn't have any policies on how to handle those types of things at the time, and definitely no consistent practice. We made some management changes around that time, including the Administrator and Director of Nursing. Then we had a complaint survey and they found we weren't identifying things like this as something we should investigate, and we got a deficiency. I can tell you what should happen now. If the nurse sees bruising, (he/she) would generate an Unusual Occurrence Report which starts a whole investigation that includes notifying the doctor and making sure we have treatment going. I agree 14 days was too long, and there were too many signs that (he/she) may have had a fracture at the time. I wouldn't want to wait that long, and I wouldn't want my parent to wait that long. The DOQ stated it was not the facility's practice to monitor bruising each day or each shift, only that the nurse should continue to document on it daily until it was resolved. The DOQ stated the facility did not have a system or policy for how frequently to monitor residents for pain, and typically a pain assessment was only completed if a nurse used an as needed pain medication for a resident. An interview with CNA #1, CNA #2, and CNA #6 on 3/5/20 at 5:45 pm revealed CNA #1 had been on duty on 9/9/19 when she noticed Resident #15's right foot had fallen off of the foot pedal and was dragging under the wheelchair at an odd angle as the resident was propelling his/herself towards the dining table. CNA #1 stated she told the nurse about it at the time and the nurse instructed him/her to put the resident's foot back on the foot pedal. CNA #1 stated he/she was not sure if the nurse did anything else when he/she was informed, and that the nurse was a traveling nurse who no longer worked in the facility. CNA #1 stated the following day, when the bruising was noted, she reminded the nurse of the wheelchair pedal incident the day before. CNA #1 stated at that time, the nurse told one of the people down the hill, gesturing towards a nearby building where the nurse managers and other administrative personnel have offices. CNA #6 stated he/she worked with the resident over the next few days, and the resident's foot kept falling off the foot pedal and getting caught either in or under the foot pedals. So finally, the nurse tied a sheet behind the resident's foot pedals to keep his/her feet in place. CNA #6 stated a few days after that, an x-ray was done, we got a padded footrest, and they put a cast on (his/her). The CNAs reported the foot appeared to be causing pain for the resident when it would fall off the foot pedal and drag behind or under the footrests but improved once the padded footrest was in place and the cast was placed. Both CNAs denied that Resident #15 fell at any time, as documented in the physician's progress note. An interview with the DOQ on 3/6/20 at 10:00 am revealed the facility did not have a policy regarding monitoring a change in resident condition, physician notification, or pain management. The DOQ stated, We had a really hard time with our previous medical director, in terms of policies and communication. Our new medical director has not been here long enough to fix anything yet, he is trying to concentrate on assessing each of the residents first. On 3/6/20 at 12:01 PM, an interview with Resident #15's physician, who was also the facility's Medical Director (MD), revealed that the MD had assumed care of Resident #15 in January 2020, and could not speak to the timeframe between Resident #15's injury and [DIAGNOSES REDACTED]. The MD stated if the resident had bruising and showed signs of pain that is unusual for his/her or unrelieved with current treatments then 14 days was too long to wait to have it addressed. The nurse in charge of Resident #15's care at the time of the incident, and his/her previous physician, were unavailable for interview during the survey and are no longer employed by the facility.

Based on observation, interview, and record review, the facility failed to provide care and services to maintain adequate nutrition for one resident (Resident #15) of 15 total sample residents. This failure resulted in the harm of severe weight loss for a resident with a stage 3 pressure ulcer. Findings: Review of Resident #15's Face Sheet revealed he/she was admitted to the facility on [DATE]. Review of his/her [DIAGNOSES REDACTED]. Review of Resident #15's Registered Dietician (RD) progress notes dated 9/13/19 revealed, . continues to be fairly stable nutritionally, generally eating 75-110% of 2-3 meals/day and 1-2 snacks . Review of Resident #15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/24/19, revealed he/she was unable to participate in a cognitive assessment but was evaluated by staff as having severely impaired decision making abilities, did not reject cares, required limited assistance after set-up for eating, had an unhealed stage 3 pressure ulcer, and had experienced unplanned weight loss of greater than 5% in 30 days or 10 % in 180 days. Review of Resident #15's RD progress notes dated 10/25/19 revealed, . overall has declined nutritionally . intake is only fair at 25-100% 2-3 meals/day and occasional snack; fluid intake is also fair at 1000-1500 (milliliters)/day generally . Weight has been trending down slowly in previous 6 months from being stable at (approximately) 140 lbs. Current weight loss is (approximately) 14 lbs. or 9.4% in 6 months and 5.6 (pounds) or 4.3% in 1 month. This is concerning nutritionally. Discussed with staff who do state intake has declined. Encouraged them to assist and promote improved (oral) intake as able. Suggest to increase supplements to (twice daily) and change to Boost Plus . There was no physician's order written or documentation that the staff followed the RD's suggestions. Review of Resident #15's RD progress notes dated 11/7/19 revealed, . (His/Her) weight is slowly trending down, now with a loss of (approximately) 15 lbs. in 6 months. Intake is poor and he/she is having days where (he/she) is documented with no intake of meals . fluid intake is better so perhaps increasing Boost Glucose Control to (twice daily and as needed) . would help . No order written or documentation the Boost Glucose Control was increased or provided to the resident. Review of Resident #15's RD progress notes dated 11/21/19 revealed, . reviewed plan of care and emailed (physician) with continued concerns for (Resident #15's) weight . per verbal order, added Magic Cup (ice cream type supplement) in the afternoon and (as needed) for poor (oral) intake . No order was written or documentation the Magic Cup was provided and consumed by the resident. Review of Resident #15's Physician's Progress Note, (by previous physician), dated 12/2/19 revealed unintended weight loss listed as part of the Current Problem List, as well as a stage 3 pressure injury to the right buttock which had been present since March 2019. The MD progress note documented current supplements as [MEDICATION NAME] two scoops with breakfast and Boost Glucose Control 240 milliliters with breakfast. The physician's progress note did not document additional routine or as needed Boost available, or the inclusion of a Magic Cup. The progress note documented Resident #15 had multiple abnormal laboratory values noted from the last laboratory draw on 10/22/19, including hemoglobin at 5.0 (normally 12 - 16). No follow-up could be found in the record to the abnormal laboratory values. Review of Resident #15's significant change of condition MDS with an ARD of 1/7/20, revealed he/she was unable to participate in a cognitive assessment but was evaluated by staff as having severely impaired decision making abilities, did not reject cares, required limited assistance after set-up for eating, had an unhealed stage 3 pressure ulcer, and had experienced unplanned weight loss of greater than 5% in 30 days or 10 % in 180 days. On 10/1/19, the resident weighed 130.2 lbs. On 1/7/20, the resident weighed 119 pounds which is a -8.60 % loss. Review of Resident #15's care plan under the Need/Preference (dated 1/14/20) of I experience unintended weight loss because I have dementia, need reminders to keep eating. I show this by 11.5% weight loss (17 lbs.) in previous 6 months and meet criteria for moderate protein/calorie malnutrition . revealed the approaches of, . serve large portions at breakfast because I eat best at breakfast time . encourage me to consume adequate protein, fluid, and meal intake to promote wound healing and stabilize weight loss . continue to monitor need to adjust supplement type and/or amount daily . beginning 1/14/20. The facility could not provide a previous care plan for Resident #15. Review of Resident #15's RD progress notes dated 1/15/20 revealed, . has continued to decline nutritionally . he/she is ordered to receive supplements Boost Plus (twice daily) . and Magic Cup in the afternoon, and both can be used (as needed) . RD has observed Elder at meal times occasionally making no effort to eat. Encouraged staff to assist him/her as needed to promote improved (oral) intake . meets the criteria for moderate protein/calorie malnutrition . Recommend assisting Elder as needed with eating . Review of Resident #15's physician's orders revealed a diet order on 1/24/20 for Level II Mechanically Altered (Moist Ground) food texture; two scoops of [MEDICATION NAME] in coffee or yogurt each morning; Boost Glucose Control (no amount specified) morning, afternoon, and as needed; and a Magic Cup every afternoon and as needed. The supplement orders specified a [DIAGNOSES REDACTED]. Orders given per current physician. On 11/5/19, the resident weighed 125.4 lbs. On 2/5/20, the resident weighed 114.4 pounds which is a -8.77 % loss. Review of Resident #15's RD progress notes dated 2/14/20 revealed, . continues to decline nutritionally despite adjustments to (his/her) supplement regimen . requiring more assistance with feeding, but often refuses help. RD has observed (him/her) at meals making no effort to eat . Review of Resident #15's care plan under the Need/Preference of I can't complete my cares on my own because I have [MEDICAL CONDITION] and I show this by not participating in my ADLs . revealed the approach of, . I eat but I need to be fed . beginning 2/19/20. Review of Resident #15's nutritional supplement Certified Nursing Assistant (CNA) documentation for 1/1/20 through 3/4/20 in his/her CNA tasks revealed the facility did not document which of his/her supplements had been provided, the quantity provided, or how much of the supplement was consumed. Review of Resident #15's Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. Review of Resident #15's meal intake documentation for 1/1/20 through 1/31/20 revealed: Breakfast: Did not eat seven of 31 opportunities (times offered), ate 25% three of 31 opportunities, ate 50% five of 31 opportunities, ate 75% of breakfast three of 31 opportunities, and ate 100% 13 of 31 opportunities. Morning snack: Did not eat 31 of 31 times. Lunch: Did not eat seven of 31 opportunities, ate 25% nine of 31 opportunities, ate 50% four of 31 opportunities, ate 75% five of 31 opportunities, ate 100% six of 31 opportunities. Afternoon snack: Did not eat 24 of 31 opportunities, ate 100% seven of 31 opportunities. Review of Resident #15's meal intake documentation for 2/1/20 through 2/29/20 revealed: Breakfast: Did not eat 11 of 29 opportunities, ate 25% four of 29 opportunities, ate 50% two of 29 opportunities, ate 75% one of 29 opportunities, ate 100% 11 of 29 opportunities. Morning snack: Did not eat 28 of 29 opportunities, ate 100% one of 29 opportunities. Lunch: Did not eat six of 29 opportunities, ate 25% five of 29 opportunities, ate 50% six of 29 opportunities, ate 75% two of 29 opportunities, ate 100% 10 of 29 opportunities. Afternoon snack: Did not eat 20 of 29 opportunities, ate 50% one of 29 opportunities, ate 100% seven of 29 opportunities. Dinner: Did not eat five of 29 opportunities, ate 25% three of 29 opportunities, ate 50% one of 29 opportunities, ate 75% one of 29 opportunities, ate 100% 19 of 29 opportunities. An interview with Licensed Nurse (LN) #1 on 3/2/20 at 9:30 am revealed he/she was a traveling nurse and this was his/her second day working in the facility. The LN stated he/she covered both the Raven Lodge, where Resident #15 resided, and the Lupine Lodge, which was housed in the building next door. The LN stated he/she had received a brief orientation to the residents and expectations of how to divide his/her time between the two lodges and, It seems I will spend the bulk of my time in the other lodge because those residents get more medications. During a dining observation on 3/2/20 at 12:03 pm, Resident #15 was sitting at the dining table in his/her wheelchair. Certified Nursing Assistant (CNA) #1 placed a bowl of pureed food, a glass of water and a glass of juice, and a plastic spoon in front of Resident #15. CNA#1 sat between Resident #15 and another resident. CNA #1 began to assist the other resident with his/her meal but did not assist Resident #15. At 12:09 PM, Resident #15 picked up his/her plastic spoon and laid it upside down on top of his/her water glass but did not attempt to eat. At 12:10 pm, CNA #1 placed a metal spoon into Resident #15's bowl and instructed him/her to eat but provided no assistance. Resident #15 picked up the spoon without scooping any food into the bowl of the spoon, placed the empty spoon in his/her mouth, removed the spoon, scowled at it, and dropped it on the floor. CNA #1 picked up the spoon, left the table, then returned with a new spoon. Resident #15 picked up the spoon but did not attempt to eat. CNA #1 instructed Resident #15 to eat and gestured towards his/her own mouth. Resident #15 laid the spoon on the table next to his/her bowl and mimicked CNA #1's pointing gesture, then dropped his/her chin to his/her chest. At 12:13 pm CNA #1 instructed Resident #15 to eat. Resident #15 picked up the spoon and tapped it on the side of the bowl but did not attempt to feed him/herself. Resident #15 laid the spoon on the table again. At 12:17 pm, Resident #15 picked up the spoon, dipped the back of the spoon into his/her food, then placed the spoon in his/her mouth and licked the food off the back of the spoon. At 12:23 pm, Resident #15 again placed her spoon in the bowl of food, though the spoon was upside down. Resident #15 placed the spoon, still upside down, into her mouth then removed it and dropped it on the floor. At 12:36 pm, CNA #1 removed Resident #15's bowl from the table and told Resident #15 he/she did not have to eat lunch if he/she didn't want to. There was no LN present in the Raven Lodge during this observation. On 9/3/19, the resident weighed 133.2 lbs. On 3/3/20, the resident weighed 113.8 pounds which is a -14.56 % loss. An observation to observe the weighing of this resident was not made available. Observations made of Resident #15 on 3/3/20 revealed the resident was in his/her bed and asleep at 7:30 AM. An interview with CNA #3 at that time revealed Resident #15 had not yet been up that morning and had not had breakfast. CNA #3 reported that Resident #15 would remain in bed until after the wound nurse arrived to change the dressing on (his/her) coccyx wound, then staff would get the resident up for breakfast. No staff were observed to approach Resident #15's room until the wound nurse arrived. At 9:54 am, the wound nurse and CNA #1 were observed to go into Resident #15's room. At 10:11 am, CNA #1 brought Resident #15 to the dining table in a wheelchair and went into the kitchen area of the lodge to prepare Resident #15's breakfast. CNA #1 demonstrated how (he/she) placed a frozen puree regular size portion of French toast into a steamer. At 10:40 am, CNA #1 removed the pureed food from the steamer, placed it into a bowl, brought it to the table, and assisted Resident #15 to eat. Resident #15 was receptive to assistance and consumed the entirety of the meal. Resident #15 made no attempt to feed (himself/herself) during the observation. An interview with Resident #15's physician, who was also the facility's Medical Director (MD) on 3/3/20 at 11:30 am revealed the MD had assumed care for Resident #15 in late January from the previous medical director. The MD stated the facility had apprised him of Resident #15's pressure ulcer, which he had just examined, but had not made him aware the resident was also losing weight. The MD stated that though he had not had a chance to evaluate Resident #15's weight loss, in general he would expect staff to follow physician's orders for diet and supplements, document the amount of supplements consumed to evaluate their effectiveness as an intervention, and offer cues and assistance at meals per the resident's plan of care. The physician stated a resident's nutritional status was very important in promoting wound healing. Resident #15's previous physician was no longer available for interview at the time of survey. An interview with Resident #15's Family Member (FM) on 3/3/20 at 11:27 am revealed the FM had been informed about a week and a half ago that the resident was losing weight for the past 6 months. The FM reported, They told me (he/she) just wasn't interested in food anymore. The FM stated (he/she) did not live nearby and as such was unable to visit the resident regularly. The FM stated they were not sure what interventions the facility had implemented to address Resident #15's weight loss. On 3/3/20 at 4:47 pm, Resident #15 was observed sitting at the dinner table with a bowl of pureed chicken noodle soup in front of him/her. The resident was sitting with his/her head down, chin on her chest, and eyes closed. He/she was not eating. CNA #1 and CNA #3 were sitting at the table, each of them feeding a different resident. Neither CNA had offered cues or assistance to Resident #15 by the end of the observation at 5:02 pm. te resident failed to consume any of the meal. There was no LN in the lodge during this meal observation. An observation of the lunch meal on 3/4/20 at 11:22 am revealed Resident #15 readily accepting assistance from CNA #6 to consume his/her lunch. The resident ate 100% of the meal when provided assistance. There was no LN in the lodge during this meal observation. On 3/4/20 at 4:26 pm, an interview with CNA #1 and CNA #3 revealed they were the primary caregivers for Resident #15. The CNAs reported they both knew Resident #15 required assistance at meals and had informed the MDS nurse of this approximately one month ago so the resident's care plan could be updated. The CNAs reported they had not assisted Resident #15 during the meal observations when a third staff member was not available because there were two other residents who required assistance to eat and they had been told they could only assist one resident at a time due to infection control concerns. The CNAs reported that they were aware Resident #15 had been losing weight, but they had been instructed they only had to inform a nurse if a resident lost more than three pounds in a week. CNA #1 stated, If a resident loses more than three pounds in a week, I have to send an email to the people who work down there (gesturing towards the building where the nurse managers and other administrative personnel have offices), but (Resident #15) was only losing about two and a half pounds a week. CNA #1 stated that since Resident #15's weight loss never met the criteria for email notification, he/she told whoever was the nurse for Resident #15 whenever these losses were noted. CNA #1 stated, The problem is, we don't see the nurse very much down here (Raven Lodge), and it's usually a traveling nurse anyway. We can tell them, but there might be another nurse the next day. The CNAs reported they were responsible to administer Resident #15's supplements but were unable to access the physician's orders. CNA #1 stated he/she knew Resident #15 was to have a Boost supplement with breakfast and dinner but did not know about the Magic Cup. CNA #1 stated he/she was not aware that Resident #15 could have additional Boost or Magic Cups as needed and did not know how he/she would determine when to administer an as needed supplement. CNA #1 stated they did not always chart on the meal or snack logs that they had given Resident #15 a supplement or whether the resident had consumed it. CNA # 1 stated, I didn't know it was important to do that. I thought they just knew if she was getting them or not. On 3/5/20 at 10:35 am, interview with the MDS nurse revealed he/she recalled CNA #1 and CNA #3 telling him/her Resident #15 was no longer feeding himself/herself and the care plan needed to be adjusted, which is when he/she updated the resident's Activities of Daily Living (ADL) care plan to reflect that need. The MDS nurse stated he/she was not sure what approaches were in Resident #15's nutritional care plan, as it was the RD who developed that portion of the resident's care plan. The MDS nurse stated he/she was not sure where the facility documented that supplements were given or how much was consumed. On 3/5/20 at 1:50 pm, an interview with the RD revealed Resident #15 had been declining nutritionally for about a year. The RD stated Resident #15's intake and ability to feed his/herself has really, really dropped off. The RD stated, The problem as I see it is (he/she) does not get the assistance (he/she) needs with eating. (He/She) can refuse assistance vehemently at times, but often I see (him/her) sitting there with food in front of (him/her) and nothing is going on. (He/Her} head is down, eyes are closed, and no one is paying attention to (him/her). The RD described Resident #15's current nutritional status as, Borderline moderate to severe malnutrition. The RD stated he/she was also frustrated with the lack of documentation regarding whether supplements had been provided or were consumed. The RD stated, As far as I can tell, if it's documented, it's documented in with the fluid intakes. But since they don't break out which fluid the resident consumed, I don't know if (he/she) was drinking water or Boost. The RD responded, Absolutely not when asked if the current information he/she received from the facility regarding Resident #15's supplement intake was adequate to accurately assess the effectiveness of those interventions. The RD stated he/she reviewed the weights for all residents in the facility weekly, including Resident #15, and was aware that the resident had experienced significant weight loss. The RD stated he/she had repeatedly emailed the Interim Director of Nursing (IDON) about Resident #15's weight loss along with concerns that Resident #15 was not getting assistance consistently and supplements were not being documented but had received no response. On 3/5/20 at 4:46 pm, an interview with the IDON revealed, There was a disconnect in communication between the dietician and the whole team. I was not aware until today that (Resident #15) had been losing weight. The IDON stated he/she had been working in the facility for approximately six months and had been concentrating on other aspects of resident care that were more pressing than weight loss, especially since he/she did not know the facility had a resident with the degree of weight loss Resident #15 had experienced. Regarding the administration of a supplement, the IDON stated it would not necessarily be her expectation that the LNs administer supplements when the physicians order them, but if CNAs are administering those supplements to the residents they should be documented. The IDON stated, I was informed by my team today that the documentation of whether they were given is hard to find. The IDON stated, The CNAs can access physician orders. There's no reason they shouldn't know if the residents should be getting a supplement. They also know they can feed more than one resident at a time, and it's not true that they have to wait for a resident to lose three pounds in a week before they email me. The IDON stated he/she was not sure whether the facility had policies on administration of supplements, weight loss, or assisting residents with eating. The IDON stated it would have been his/her expectation that Resident #15 had received his/her supplements and diet texture as ordered by the physician, assistance at meals per his/her plan of care, and other interventions such as larger portions at breakfast as recommended by the RD. On 3/6/20 at 10:00 am an interview with the Director of Quality (DOQ) revealed the facility did not have policies on ADLs, following physician's orders, or administration of supplements. The DOQ stated it was not always the practice of Resident #15's previous physician to include RD recommendations like supplements as a physician's order, and often that physician did not want things such as consumption documented by an LN. The DOQ stated, That's a bummer, really, given how much weight (heshe) lost. Review of the Facility Nutrition Program policy, dated 3/2019, revealed, . Ensure that the Elders are served the correct prescribed diet & ordered adaptive equipment . Evaluate food and fluid intake for each Elder and document amounts eaten . Assess nutritional needs and risks of all Elders in the facility, help assure appropriate meals & other nutritional interventions are provided . Assist staff in identifying specific factors in individual Elders (medical conditions, medications, etc.) that may be affecting an Elder's appetite, nutritional needs, nutrition utilization, and hydration status .

Based on record review, observation and interview the facility failed to ensure 2 residents (#s 12 and 18) out of 12 sampled residents received care and services to prevent the development of pressure ulcers. This failed practice caused 1 resident (#12) to receive an unstageable pressure ulcer and 1 resident (#18) to receive a Stage III (a wound where full thickness tissue loss occurs) pressure ulcer. Findings: Resident #18 Record review from 10/1-5/18 of Resident #18's medical record revealed the Resident was admitted with [DIAGNOSES REDACTED]. The Resident received nutritional supplements via a PEG tube (Percutaneous Endoscopic Gastrostomy - a feeding tube inserted into the stomach through the abdomen). Review of the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], revealed the Resident was coded as having short and long term memory problems, bilaterally impaired on both upper and lower extremities. Further review revealed Resident #18 was totally dependent on staff for bed mobility; transferring; dressing; eating; toilet use; personal hygiene; and bathing. In addition, the MDS had the resident had a history of [REDACTED]. Review of Resident #18's care plan, last updated 7/9/18, revealed the a problem of At risk for Alteration in skin integrity due to history of pressure wound, impaired mobility, contractures, dependence on staff, urinary and fecal incontinence, impaired cognition and the Resident prefers to assume a side lying position. Interventions included to assess and monitor skin status, reposition at regular intervals and float heels. Random observations from 10/1-8/18 revealed the Resident favored his/her right side when up in wheeled-tilt chair with no padding or positioning device on the Resident's right side of body. During random observations every other hour (while Resident was up 10/1-3/18) revealed the Resident was always leaning to the right. Further review revealed the Resident was sent to the hospital for treatment of [REDACTED]. Right Elbow Wound Decline Timeline: Further review of the medical record from 10/1-8/18 revealed the following findings: Record review of the Admission Skin Assessment, dated 5/30/18 at 2:52 pm and 7:13 pm, revealed no wounds to right elbow. Further review revealed the resident did have a heel ulceration that was acquired during the hospitalization . Record review of a document titled Wound Care Visit, dated 5/31/18, revealed Resident #18 no documentation of a right elbow wound. During an interview on 10/3/18 at 3:30 pm the Wound Care Nurse (WCN) stated the Resident went to Physical Therapy for evaluation of a heel wound. In addition the WCN stated no assessment of the right elbow was completed. When asked about the process of skin assessments after hospitalization , the WCN stated that when a resident arrives from the hospital the staff should contact the lodge LN to do a complete skin assessment. Record review of the nursing notes, dated 6/5/18, a loss in skin integrity was noted to the Resident's right elbow, 5 days after readmission to the long term care facility. Record review of the Weekly Skin Assessment, dated 6/5/18 at 2:19 am, revealed (Resident's) blister on his right elbow is red and still has small amount of fluid in it. Measured approximately 1.2 centimeters (cm) x 1 cm. During an interview on 10/4/18 at 8:53 am the LTCM stated he/she reviewed the chart and the first documentation of the right elbow wound occurred on 6/5/18 (5 days after Resident arrived back form hospitalization ). Record review of a physician's note, dated 6/6/18, from Primary Care Provider (PCP) #2 revealed there is a 1 centimeter (cm) diameter superficial abrasion present at right elbow . During an interview on 10/4/18 at 2:42 pm PCP #2 stated the area, in reference to the 6/6/18 physician's note, appeared to be a superficial scrape-like wound. PCP #2 it was minor in relation to skin integrity loss and/or damage. Record review of a document titled Wound Care Visit, dated 6/7/18, revealed Resident #18's right elbow wound was described as an intact blister which measured length 2.6 cm, width 1.0 cm with no depth. The Physical Therapist documented: New wound 4x4 Allevyn dressing in place .nurse replaced with new Allevyn dressing. Record review of the Weekly Skin Assessment, dated 6/11/18 at 5:33 am, revealed: Allevyn (dressing) to right elbow for pressure reduction and protection of fragile skin which appears intact and healing but a purple/red color wound bed. Record review of a physician's note, dated 6/13/18, from PCP #3 revealed a stage 3 pressure injury to the right elbow. This pressure injury is measured as length 2.1 cm, width 1.3 cm with no depth. PCP #3 documented: pressure injury to right elbow over the olecranon (bony prominence of elbow). Wound obtained during recent hospitalization . Record review of a physician's note, dated 7/3/18, from Primary Care Provider (PCP) #2 revealed upon physical exam: there is a 1 centimeter (cm) diameter superficial abrasion present at right elbow . Record review of a physician's note, dated 7/12/18, from PCP #3 revealed: Pressure injury of right elbow, stage 3: wound is resolved. Well healed. No further wound care required . Record review of a physician's note, dated 8/9/18, from PCP #3 revealed: Nurse reports that staff have had increased difficulty placing a right elbow protector on (Resident) .They also have noted areas of ecchymosis (discoloration of the skin) on the upper arm distal end and on the elbow. Further review revealed Ensure patient is positioned to offload the right elbow in wheelchair and in bed. Further review revealed an unstageable pressure injury to the right elbow with a date of origin 8/9/18 and origination was Seward Mountain Haven. Documented assessment and plan: Area of dark purple discoloration/ecchymosis over right elbow where elbow rests against wheelchair armrest. Nurse reports right arm contracted at the elbow and application of elbow protector has been very difficult .Possible deep tissue injury. Record review of a physician's note, dated 9/5/18, from PCP #2 revealed: Skin concerns are largely resolved. Record review of a physician's note, dated 9/20/18, from PCP #3 revealed: Unstageable pressure injury, right elbow: Discolored area on right elbow has resolved. Wound never became open. Skin is intact. During a second interview on 10/4/18, the LTCM stated it appeared the facility staff failed to properly assess and document the integrity of Resident #18's skin. The LTCM stated the area to the right elbow did decline while Resident was in the facility. In addition, the LTCM stated the facility should have provided additional education and training to the nursing and Shabaz staff. Additional review of Resident #18's care plan, last updated 7/9/18, of the a problem At risk for Alteration in skin integrity revealed no approaches or interventions related to the right elbow risk of pressure injury. Resident #12 Record review from 10/1-5/18 of Resident #12's medical record revealed the Resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set), an quarterly assessment dated [DATE], revealed Resident #12 was coded as having unclear speech; requiring extensive assistance with peri-care and bed mobility; impaired upper and lower extremities, and frequently incontinent of bowel and bladder. Further revealed the Resident was coded as the Resident was not a risk for developing pressure ulcers. Review of the Resident's Braden Scale (tool used to determine risk for pressure injuries), dated 7/18/19 (one day prior to MDS assessment), revealed the Resident was at moderate risk for development of pressure injuries. Review of the Resident's care plan, last updated 7/9/18 revealed the resident requires assistance with moving and hygiene due to impaired cognition, impaired mobility, pain and one-sided weakness. Further review revealed the care plan identified the Resident as being at risk for alteration in skin integrity with approaches that included the Shabazims were to report changes in skin status to the Licensed Nurse (LN). An observation on 10/2/18, during morning cares, a .4 cm by .4 cm dark purple circular deep tissue injury, on the backside of the Resident's right heel, was observed during the observation. Shabazims #s 9 & 12 were unaware of the dark purple wound at the time of discovery. When asked what would be the next step in the process, Shabaz #9 stated the LN needed to be notified. During an interview on 10/3/18 at 4:31 pm the Wound Care Nurse (WCN) stated staff should have noticed the area to Resident #12's right heel and reported it immediately. The WCN further stated the staff LN was not notified of the wound and was unaware of the area of concern. During an interview on 10/4/18 at 8:57 am the Long Term Care Manager (LTCM) stated neither nursing nor management was notified of the dark purple circular area to Resident #12's right heel since discovery by Surveyor on 10/2/18. The LTCM stated the Resident has neuropathic pain in his/her feet which would have made it difficult to feel wound development. Record review on 10/4/18 of a document titled Wound Care Visit, dated 10/4/18 at 9:40 am revealed the Resident had a pressure injury 0.4 cm by 0.4 cm in size. Review of the weekly skin assessments, performed by LNs, dated 9/13/18; 9/21/18; and 9/27/18 revealed no indication or notes regarding skin integrity issues located to the right heal. Further review revealed a wound assessment, dated 10/3/18 at 4:48 pm, that indicated Right heel dark purple area (noted) cover with small allevyn (wound dressing), float heel. Wound care nurse to follow-up. During an interview on 10/4/18 at 8:57 am the Long Term Care Manager (LTCM) stated neither nursing nor management was notified on 10/2/18 of the dark purple circular area to Resident #12's right heel after the discovery by Surveyor on 10/2/18. The LTCM stated the Resident has neuropathic pain in his/her feet which would have made it difficult to feel wound development. The LTCM contained to state the Resident likes his/her feet to be wrapped with snug fitting wrapping material. The Long Term Care Manager stated the Shabaz staff should have noted the area and reported it to the nurse for evaluation and assessment. The Manager indicated the Shabaz should be more thorough during cares. Review of the facility provided document titled Daily Care Standards, dated 10/4/18, revealed Care Plans .Report changes of condition promptly to Nurse . Morning Care .Inspect skin for rashes, trauma, or pressure injuries. Report any issues/concerns in a timely manner to Nurse Report to Nurse any unusual occurrences or changes of condition such as .skin .Document care provided and observations accurately and timely

Based on record review, observation, and interview the facility failed to provide timely intervention for the prevention of pain for 1 resident (#2) of 6 sampled residents. This failed practice caused resident #2 unnecessary pain and placed the resident at risk for further suffering from undertreated pain. Findings: Record review on 5/5-8/14 revealed Resident #2 was admitted with [DIAGNOSES REDACTED]. Review of the most recent pain assessment, dated 5/1/14, revealed Resident #2 responded "Almost constantly" to the question, "How much of the time have you been experiencing pain or hurting over the last 5 days?" This pain assessment also revealed the Resident responded with," 'Oh yeah that helps' when cream applied with back massage." Review of the quarterly MDS, dated [DATE], revealed patient pain assessment coded "almost constantly" when asked "how much of the time have you experienced pain or hurting over the last 5 days?" Further review of the MDS revealed patient rated pain as "severe" and responded "yes" when asked, "has pain made it hard for you to sleep at night?" Review of the MAR indicated [REDACTED]. Review of MD progress notes from 5/6/14 revealed Resident #2 complained of back and shoulder pain and "says cream helps". The MD note also referred to this cream as the "pain relieving rub cream". During an observation on 5/6/14 at 9:50 am, Resident #2 complained of pain in "my legs" and asked for the cream. Shahbaz #2 asked Resident #2 if she wanted her pain cream and stated she would tell the nurse. At 10:00 am RN #2 gave Resident #2 [MEDICATION NAME] sodium (a medication for [MEDICAL CONDITION] function) and the Resident complained to the RN of pain in her legs and back. Resident #2 again asked for the cream for her legs and back. The RN then instructed Shahbaz #2 to use regular lotion for now and stated she would get medicated pain cream later. Resident #2 asked RN #2, "Are you going to give me more pills?" The RN replied, "I'm going to wait 30 minutes after that [MEDICAL CONDITION] medication." A few moments later Resident #2 told Shahbaz #2, when describing pain, "Sometimes when I get to the toilet, I can't get off." Shahbaz #2 responded, "I know that's true", while rubbing Resident #2's back with the non-medicated lotion. RN #2 then stated, "I'm going to find that cream after breakfast." During an interview on 5/6/14 at 10:00 am when questioned about the Resident's pain, Shahbaz #2 responded, "She's in constant pain." Continued observations on 5/6/14 at 10:30 am revealed RN #2 gave the Resident 2 Tylenol at 10:30 am. During the observation, Resident #2 continued to complain of pain. Resident was not offered the Menthol-[MEDICATION NAME] Cream at that time. During an observation on 5/7/14 at 9:15 am, Resident #2 complained of pain so bad she could barely walk and needed to lay back down. RN #3 gave Tylenol but did not offer the Menthol-[MEDICATION NAME] Cream. Further MAR indicated [REDACTED]. Record review performed 5/5-8/14 of Resident #2's care plan revealed a problem of "alteration in comfort" with the following goals: "IDT (interdisciplinary department team) has determined that her pain goals are that elder is still able to sleep, participate with cares and engage in activities that she seems to enjoy" and "pain is reduced or relieved within 30-45 minutes after staff intervention." One care planned approach was "encourage elder to report pain at first onset to prevent escalation of pain to promote prompt staff intervention to reduce or relieve pain." Review of pain management policy, dated 6/1/09, stated "In keeping with the philosophy and mission of Providence Health Care System, Providence Seward Mountain Haven, will ensure the highest level of quality care for elders by its commitment to managing pain. It is every elder's right to have his or her pain aggressively managed." After multiple attempts 5/8/14, the surveyor was unable to reach the facility's consultant pharmacist. The State of Alaska HSS Pharmacist, verified 5/12/14 that [MEDICATION NAME] could be given with Tylenol. The online package insert for [MEDICATION NAME] ([MEDICATION NAME] sodium tablet) retrieved 5/12/14 does not show a contraindication for administering [MEDICATION NAME] simultaneously with Tylenol. .

Based on observation, interview, and record review, the facility failed to ensure its resources were effectively and efficiently used to attain or maintain the highest practicable, physical, mental and social well being of all residents. These failures led to the facility's inability to maintain substantial compliance with regulatory requirements, and resulted in: Immediate Jeopardy at 483.25(h) Accidents, twice; Immediate Jeopardy at 483.25 Quality of Care; and a finding of substandard quality of care at 483.15 Activities. Findings: Failure to administer the facility in a manner in which its resources were effectively and efficiently used resulted in failures noted in the following regulatory areas: 483.10(b)(3) Informed in Advance About Care and Treatment 483.10(d)(3) Participation in Planning Care 483.15 Activities 483.15(g) Social Services 483.20(k) Develop Comprehensive Care Plans 483.20(k)(2) Review and Revise Comprehensive Care Plans 483.20(k)(3) Professional Standards of Quality 483.25 Quality of Care 483.25(h)(1)Resident Environment Free of Accident Hazards 483.25(h)(2) Receive Adequate Supervision to Prevent Accidents 483.60(c)(2) Drug Regimen Review 483.65(a) Infection Control, Isolation Procedures 483.65(c) Infection Control, Linens 483.75(l)(3) Safeguarding Clinical Records Against Unauthorized Use 483.75(o) Quality Assessment and Assurance

Based on observation, interview, and record review, the facility failed to ensure its resources were effectively and efficiently used to attain or maintain the highest practicable, physical, mental and social well being of all residents. These failures led to the facility's inability to maintain substantial compliance with regulatory requirements, and resulted in: Immediate Jeopardy at 483.25(h) Accidents, twice; Immediate Jeopardy at 483.25 Quality of Care; and a finding of substandard quality of care at 483.15 Activities. Findings: Failure to administer the facility in a manner in which its resources were effectively and efficiently used resulted in failures noted in the following regulatory areas: 483.10(b)(3) Informed in Advance About Care and Treatment 483.10(d)(3) Participation in Planning Care 483.15 Activities 483.15(g) Social Services 483.20(k) Develop Comprehensive Care Plans 483.20(k)(2) Review and Revise Comprehensive Care Plans 483.20(k)(3) Professional Standards of Quality 483.25 Quality of Care 483.25(h)(1)Resident Environment Free of Accident Hazards 483.25(h)(2) Receive Adequate Supervision to Prevent Accidents 483.60(c)(2) Drug Regimen Review 483.65(a) Infection Control, Isolation Procedures 483.65(c) Infection Control, Linens 483.75(l)(3) Safeguarding Clinical Records Against Unauthorized Use 483.75(o) Quality Assessment and Assurance

Based on observation, interview, and record review the facility failed to assess, and provide timely interventions with monitoring for 1 resident (#1) whose volatile behaviors were negatively affecting the physical, mental, and psychosocial well-being of the 7 other residents (#s 1; 5; 13; 14; 15; 16; and 17) in 1 of 4 Lodges (based on a census of 34), and failed to minimize pain and promote comfort for 2 residents (#s 4 and 10) with documented pain, out of 8 sampled residents. Without appropriate assessment, care plan interventions, and monitoring, residents were placed at risk for not receiving the necessary and/or appropriate care and services to ensure optimal outcomes. This failed practice constituted an immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 5/24/11 at 6 pm. The immediate jeopardy was abated onsite. Findings: Resident #1 Record review on 5/23-26/11 revealed Resident # 1 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The facility was aware that the Resident had exhibited extremely volatile behaviors prior to being admitted to the facility; behaviors were well documented in pre-screening paperwork. Observations of the Resident's behavior towards staff, from 5/23-25/11 revealed the Resident pinched, hit, and scratched Shahbaz #s 11, 12, and 3; the Dietary Manager; Speech Therapist; and the acting Director of Nursing Services. On 5/24/11 from 10:15-11:45 am, he slammed a closet door in his room multiple times, just narrowly missing Shahbaz #3's head; he tore off Shahbaz #3's protective cover-up, rendering it ineffective, and continually pinched her on the arms and legs; he threw a bag of soiled linens into Staff #12's face; at 11:15 am, when Staff #3 attempted take him back into his room to be toileted, he punched her in the mouth causing injury that needed evaluation in the emergency room ; and at 11:45 am he pinched Licensed Nurse #5 on the arm. She grimaced and her eyes fill with tears. After several minutes she again attempted to give the Resident his medications. Observations of the Resident's behavior towards other residents, from 5/23-25/11, revealed the following: on 5/23/11 during the evening meal and on 5/24/11 during a mid-morning meal, he hit at Resident #13 multiple times while she was trying to eat, causing her to pull back from him; during the evening meal on 5/23/11 and during the morning meal on 5/24/11, he forcibly pushed the large dining table from side to side, causing plates on the table to slide around and causing Resident #s 13 and 14 to be wedged between the table and their wheelchairs. On 5/23/11 at 5:43 pm, after the Resident picked up a chair located next to Resident #13 and repeatedly slammed it down on the floor, Resident #15 rose from her place at the table, took the chair away from Resident #1, and moved it across the room, then returned to her meal. During an interview after the meal, Resident #15 disclosed she was trying to protect Resident #13 from getting hurt. Observations revealed Shahbazim and nursing staff were unable to control the Resident's behaviors, and several residents were visibly upset, telling him to "stop it". During interviews on 5/24/11 at 7:45 am with Shahbaz #s 3 and 12, they both said they were afraid of Resident #1. They confirmed Resident #1 did grab at other residents and that Resident #13 was especially irritated by his behaviors. When asked what they were supposed to do when the Resident displayed abusive behavior. They said they were to say "(Resident name), stop! That hurts." When asked if any other interventions had been tried, or if other interventions were successful, the staff replied "we were told we couldn't talk down to the Resident or act mad at him". They disclosed interventions that had been put into place were not effective and that they did not know how to proceed to ensure residents and staff were not harmed by Resident #1. Both Shahbazim said that when they tried to talk to the administrative staff about the Resident's volatile behaviors they were told "that is just the way he is; you will just have to deal with it",and that they were not supposed to make him "feel bad" about his abusive behaviors toward staff and other residents. In addition, they said they were told to tell the other residents that "he doesn't understand what he is doing" and to tell them they needed to just stay away from him. During an interview with Resident #13 on 5/24/11 at 11:10 am, she disclosed she felt threatened by Resident #1's behavior. During an interview with Resident #15 on 5/25/at 11 am, she disclosed she was fearful for the other residents' welfare and felt she needed to "protect them" from Resident #1. She stated that Resident #1's consent yelling and slamming furniture around made it unbearable for her to stay in the Lodge. She said she had to leave every day, just to get away for some peace and quiet. When asked if they felt the Resident placed other residents at risk of being harmed, all the staff members interviewed said the Resident would hurt anyone who got within arm's reach of him. In addition, staff stated the Resident could move independently in his wheelchair when he wanted to. During an interview with the ECC (Elder Care Coordinator) nurse on 5/24/11 at 4:00 pm, she confirmed an incident had occurred where Resident #1 grabbed Resident #15 but indicated she viewed the incident as Resident #15's responsibility because "she is cognitively intact" and "was educated to stay away from (Resident name)". During an interview with the Health Unit Coordinator (HUC) on 5/24/11 at 4:30 pm, she described an incident where Resident #1 hit her 4-year-old son when they were visiting Lupine Lodge. She said that Resident #1 had not been provoked in any way. During an interview with the social worker on 5/26/11 at 3 pm she disclosed the Resident had not had a psychiatric evaluation since being admitting to the facility. When the surveyor asked to review the PASRR (Pre-Admission Screening and Resident Review, a report that lists the specialized services the individual requires) paperwork, she was unable to locate it. It was later provided; it was signed for 11/24/10 to 5/24/10. Resident #10 Record review on 5/23-27/11 revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's medication regimen included [MEDICATION NAME] (narcotic pain reliever), 1-2 tablets every 6 hours prn (as needed) for pain and Tylenol 325 mg, 2 tablets every 4 hours prn for moderate pain. The Resident did not have an order for [REDACTED]. Review of Resident #10's care plan revealed "Problem: At risk for alteration in comfort" and "Goal: Expressed satisfaction with pain med regime. (Resident's) goal is '0' (no pain)." During an interview on 5/27/11 at 8:20 am Shahbaz #13 stated she was unable to perform Range of Motion exercises for the Resident because she had too much pain in her lower extremities. During an interview on 5/27/11 at 8:20 am, Resident #10 stated "My hip hurts". During an interview on 5/27/11 at 8:45 am, when asked about management of the Resident's pain, LN #4 stated that she had requested the Resident be placed on a pain management program. Review of the Resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of nursing pain assessments revealed the following: 2/28/11 at 2:38 pm the pain level was "Very severe horrible" and was experienced "Frequently"; 3/14/11 at 9:07 pm the pain level was 7 out of "10 - Worst pain you can imagine" and was experienced "Frequently"; 3/21/11 at 4:28 pm the pain was "Very severe, horrible" and was experienced "Frequently"; 4:4/11 at 9:21 pm, the pain was "Very Bad", "Hurt all over" and "In pain daily"; 4/26/11 at 5:00pm, the pain was "Very severe, horrible" and the assessment included the statement "treatment (with prn pain medication) ineffective d/t (due to) severe pain. Elder at this time has RX (prescription) for [MEDICATION NAME] 5/325 1-2 PO (orally) q (every) 6 hours prn pain (as needed for pain). Left note for (physician) requesting an increase in [MEDICATION NAME] or shorten time allowed to be given as well as [MEDICATION NAME] for prn pain Will continue to assess and will encourage giving 2 [MEDICATION NAME] PO prior to care or dressing changes to coccyx.; 5/2/11 at 3:51 pm, the pain was rated as a "10" and "very severe horrible"; and 5/17/11 at 7:55 am, the pain was "Almost constant". Resident #4 Record review on 5/23-27/11 revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's medication regimen included [MEDICATION NAME] (narcotic pain reliever) every 6 hours prn (as needed), [MEDICATION NAME] (antianxiety) every 6 hours prn, and Tylenol every 6 hours prn. The Resident did not have an order for [REDACTED]. Review of the Resident's care plan revealed "Problem: Potential for alteration in comfort" and "Goal: (Resident) does not understand the concept of desired pain goal IDT (interdisciplinary team) has determined the pain goal=0-1." Review of a nursing pain assessment on 4/29/11 at 8:11 pm revealed "Pain is an issue more than anxiety these days". Review of the Residents Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During a telephone interview on 5/27/11 at 11:00 am, the attending physician for Resident #s 4 and 10 confirmed that if he knew there was a pattern of frequent administration of prn medications, he would write an order for [REDACTED]. Review of the facility's policy "Pain Management", effective date 6/1/09, revealed "it is every elder's right to have pain aggressively managed." .

Based on observation, interview, and record review the facility failed to assess, and provide timely interventions with monitoring for 1 resident (#1) whose volatile behaviors were negatively affecting the physical, mental, and psychosocial well-being of the 7 other residents (#s 1; 5; 13; 14; 15; 16; and 17) in 1 of 4 Lodges (based on a census of 34), and failed to minimize pain and promote comfort for 2 residents (#s 4 and 10) with documented pain, out of 8 sampled residents. Without appropriate assessment, care plan interventions, and monitoring, residents were placed at risk for not receiving the necessary and/or appropriate care and services to ensure optimal outcomes. This failed practice constituted an immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 5/24/11 at 6 pm. The immediate jeopardy was abated onsite. Findings: Resident #1 Record review on 5/23-26/11 revealed Resident # 1 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The facility was aware that the Resident had exhibited extremely volatile behaviors prior to being admitted to the facility; behaviors were well documented in pre-screening paperwork. Observations of the Resident's behavior towards staff, from 5/23-25/11 revealed the Resident pinched, hit, and scratched Shahbaz #s 11, 12, and 3; the Dietary Manager; Speech Therapist; and the acting Director of Nursing Services. On 5/24/11 from 10:15-11:45 am, he slammed a closet door in his room multiple times, just narrowly missing Shahbaz #3's head; he tore off Shahbaz #3's protective cover-up, rendering it ineffective, and continually pinched her on the arms and legs; he threw a bag of soiled linens into Staff #12's face; at 11:15 am, when Staff #3 attempted take him back into his room to be toileted, he punched her in the mouth causing injury that needed evaluation in the emergency room ; and at 11:45 am he pinched Licensed Nurse #5 on the arm. She grimaced and her eyes fill with tears. After several minutes she again attempted to give the Resident his medications. Observations of the Resident's behavior towards other residents, from 5/23-25/11, revealed the following: on 5/23/11 during the evening meal and on 5/24/11 during a mid-morning meal, he hit at Resident #13 multiple times while she was trying to eat, causing her to pull back from him; during the evening meal on 5/23/11 and during the morning meal on 5/24/11, he forcibly pushed the large dining table from side to side, causing plates on the table to slide around and causing Resident #s 13 and 14 to be wedged between the table and their wheelchairs. On 5/23/11 at 5:43 pm, after the Resident picked up a chair located next to Resident #13 and repeatedly slammed it down on the floor, Resident #15 rose from her place at the table, took the chair away from Resident #1, and moved it across the room, then returned to her meal. During an interview after the meal, Resident #15 disclosed she was trying to protect Resident #13 from getting hurt. Observations revealed Shahbazim and nursing staff were unable to control the Resident's behaviors, and several residents were visibly upset, telling him to "stop it". During interviews on 5/24/11 at 7:45 am with Shahbaz #s 3 and 12, they both said they were afraid of Resident #1. They confirmed Resident #1 did grab at other residents and that Resident #13 was especially irritated by his behaviors. When asked what they were supposed to do when the Resident displayed abusive behavior. They said they were to say "(Resident name), stop! That hurts." When asked if any other interventions had been tried, or if other interventions were successful, the staff replied "we were told we couldn't talk down to the Resident or act mad at him". They disclosed interventions that had been put into place were not effective and that they did not know how to proceed to ensure residents and staff were not harmed by Resident #1. Both Shahbazim said that when they tried to talk to the administrative staff about the Resident's volatile behaviors they were told "that is just the way he is; you will just have to deal with it",and that they were not supposed to make him "feel bad" about his abusive behaviors toward staff and other residents. In addition, they said they were told to tell the other residents that "he doesn't understand what he is doing" and to tell them they needed to just stay away from him. During an interview with Resident #13 on 5/24/11 at 11:10 am, she disclosed she felt threatened by Resident #1's behavior. During an interview with Resident #15 on 5/25/at 11 am, she disclosed she was fearful for the other residents' welfare and felt she needed to "protect them" from Resident #1. She stated that Resident #1's consent yelling and slamming furniture around made it unbearable for her to stay in the Lodge. She said she had to leave every day, just to get away for some peace and quiet. When asked if they felt the Resident placed other residents at risk of being harmed, all the staff members interviewed said the Resident would hurt anyone who got within arm's reach of him. In addition, staff stated the Resident could move independently in his wheelchair when he wanted to. During an interview with the ECC (Elder Care Coordinator) nurse on 5/24/11 at 4:00 pm, she confirmed an incident had occurred where Resident #1 grabbed Resident #15 but indicated she viewed the incident as Resident #15's responsibility because "she is cognitively intact" and "was educated to stay away from (Resident name)". During an interview with the Health Unit Coordinator (HUC) on 5/24/11 at 4:30 pm, she described an incident where Resident #1 hit her 4-year-old son when they were visiting Lupine Lodge. She said that Resident #1 had not been provoked in any way. During an interview with the social worker on 5/26/11 at 3 pm she disclosed the Resident had not had a psychiatric evaluation since being admitting to the facility. When the surveyor asked to review the PASRR (Pre-Admission Screening and Resident Review, a report that lists the specialized services the individual requires) paperwork, she was unable to locate it. It was later provided; it was signed for 11/24/10 to 5/24/10. Resident #10 Record review on 5/23-27/11 revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's medication regimen included [MEDICATION NAME] (narcotic pain reliever), 1-2 tablets every 6 hours prn (as needed) for pain and Tylenol 325 mg, 2 tablets every 4 hours prn for moderate pain. The Resident did not have an order for [REDACTED]. Review of Resident #10's care plan revealed "Problem: At risk for alteration in comfort" and "Goal: Expressed satisfaction with pain med regime. (Resident's) goal is '0' (no pain)." During an interview on 5/27/11 at 8:20 am Shahbaz #13 stated she was unable to perform Range of Motion exercises for the Resident because she had too much pain in her lower extremities. During an interview on 5/27/11 at 8:20 am, Resident #10 stated "My hip hurts". During an interview on 5/27/11 at 8:45 am, when asked about management of the Resident's pain, LN #4 stated that she had requested the Resident be placed on a pain management program. Review of the Resident's Medication Administration Record [REDACTED]. Review of nursing pain assessments revealed the following: 2/28/11 at 2:38 pm the pain level was "Very severe horrible" and was experienced "Frequently"; 3/14/11 at 9:07 pm the pain level was 7 out of "10 - Worst pain you can imagine" and was experienced "Frequently"; 3/21/11 at 4:28 pm the pain was "Very severe, horrible" and was experienced "Frequently"; 4:4/11 at 9:21 pm, the pain was "Very Bad", "Hurt all over" and "In pain daily"; 4/26/11 at 5:00pm, the pain was "Very severe, horrible" and the assessment included the statement "treatment (with prn pain medication) ineffective d/t (due to) severe pain. Elder at this time has RX (prescription) for [MEDICATION NAME] 5/325 1-2 PO (orally) q (every) 6 hours prn pain (as needed for pain). Left note for (physician) requesting an increase in [MEDICATION NAME] or shorten time allowed to be given as well as [MEDICATION NAME] for prn pain Will continue to assess and will encourage giving 2 [MEDICATION NAME] PO prior to care or dressing changes to coccyx.; 5/2/11 at 3:51 pm, the pain was rated as a "10" and "very severe horrible"; and 5/17/11 at 7:55 am, the pain was "Almost constant". Resident #4 Record review on 5/23-27/11 revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's medication regimen included [MEDICATION NAME] (narcotic pain reliever) every 6 hours prn (as needed), [MEDICATION NAME] (antianxiety) every 6 hours prn, and Tylenol every 6 hours prn. The Resident did not have an order for [REDACTED]. Review of the Resident's care plan revealed "Problem: Potential for alteration in comfort" and "Goal: (Resident) does not understand the concept of desired pain goal IDT (interdisciplinary team) has determined the pain goal=0-1." Review of a nursing pain assessment on 4/29/11 at 8:11 pm revealed "Pain is an issue more than anxiety these days". Review of the Residents Medication Administration Record [REDACTED]. During a telephone interview on 5/27/11 at 11:00 am, the attending physician for Resident #s 4 and 10 confirmed that if he knew there was a pattern of frequent administration of prn medications, he would write an order for [REDACTED]. Review of the facility's policy "Pain Management", effective date 6/1/09, revealed "it is every elder's right to have pain aggressively managed." .

Based on observation, interview, and record review the facility failed to: 1) Ensure the resident environment was free from hazardous equipment for 1 (#7) of 3 residents with wandering behaviors living in Raven Lodge, out of 8 sampled residents. This failed practice constituted an immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 5/23/11 at 1:20 pm. The immediate jeopardy was abated onsite; and 2) Ensure the safety of 1 resident (#8) with a history of potential elopement out of 8 residents residing in Lupine Lodge. This failed practice constituted an immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 5/25/11 at 7:45 pm. The immediate jeopardy was abated onsite. Findings: Unsecured Equipment Observations during the initial tour of Raven Lodge on 5/23/11 at 10:20 am revealed the door to Room 8 had a piece of yellow "Caution" tape draped from the top of the door frame. The door was unlocked and the room was unoccupied. Further observation revealed several large sheets of laminate-type flooring were on the floor. In addition, a utility knife with extra blades; 2 pair of industrial snippers, a DeWalt drill with a drill bit installed; and a caulking gun containing Color Flex2 were in the room. Observation in Raven Lodge on 5/23/11 at 10:32 am revealed Resident #7 was wandering up and down the hallway past Room 8. The Resident was holding a purse, and stated "I'm going to trash this." After wandering aimlessly, the Resident walked over to the dining room table and began picking up various items and setting them back down on the table. During an interview on 5/23/11 at 10:32 am, when asked about Resident # 7's wandering behavior, Shahbaz #8 confirmed the Resident did wander into other residents' rooms. Record review on 5/23-27/11 revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's most recent comprehensive Minimum Data Set assessment, an annual assessment dated [DATE], revealed Resident #7 was coded as having short and long-term memory loss and behavior symptoms that included rummaging 1-3 days per week. In addition, the Resident was coded as wandering, identified as placing the Resident "at significant risk of getting to a potentially dangerous place". Review of nurse's notes dated 12/20/10 and 3/11/11 revealed the Resident was observed wandering into other residents' room. At 10:42 am on 5/23/11, when the Contractor returned to Room #8, he was asked about the tools in the unsecured room. He replied the bedrooms in the Lodge did not lock. During an interview on 5/23/11 at 11:00 am with Physical Plant Service Staff #s 1 and 2, they were asked about the tools in Room 8. Staff #2 responded that he believed the equipment was locked up at night. When asked what information had been provided to the contactors regarding confused residents who wandered, Staff #2 replied this contracting company did a lot of work in health care facilities, including Providence facilities, so they should know what to do. During a second interview on 5/23/11, at 11:30 am, the Contractor stated the yellow caution tape used to be draped across the door but someone had removed it. The Contractor confirmed they had been leaving tools and other equipment in the rooms at night. When asked if the facility had provided information regarding safety or an orientation to the Lodge and residents, the Contractor replied they had not. During an interview on 5/23/11 at 1:18 pm, the Physical Plant Services Manager confirmed no training had been provided for the workers prior to working in the Lodges because this contracting company had been working in health care facilities for years. He stated the facility had no policy that addressed the safety of confused wandering residents but his expectation was that potentially dangerous equipment would be secured when unattended. On 5/23/11 at 1:20 pm facility administration was notified that leaving potentially harmful tools unsecured in a home with a Resident who was confused and who wandered constituted an immediate jeopardy to Resident # 7's health and safety. On 5/23/11 the facility abated the immediate jeopardy by removing Room 8's door handle (necessitating the use of a tool to open the door), so the room was secure. Potential Elopement Observation on 5/25/11 at 9:25 am revealed that the inner entry door to Raven Lodge was locked. After Shahbaz #8 opened the door, she was asked why the inner door was locked. The Shahbaz replied that earlier that day Resident #8 had been trying to leave the facility, so they placed a WanderGuard alarm (a device worn by a resident to help prevent elopement) in the window of the dining area, which locked the inner door. At 10:05 am on 5/25/11 the nurse for Raven Lodge, Licensed Nurse (LN) #4 was unable to open the inner door. She also questioned why the door was locked. At 10:15 am, when Resident #8 returned to her room, Shahbaz #8 removed the WanderGuard alarm from the window and said the Resident was "not going to leave now". During an interview on 5/25/11 at 5:40 pm the acting Director of Nursing Services (DNS) was asked about using a WanderGuard in Raven Lodge to keep Resident #8 from leaving. She replied that Resident #8 did not have a "strong" history of eloping, so staff would use the WanderGuard as a temporary measure to lock the Lodge. The DNS confirmed that she had given the ok for Raven Lodge staff to use the WanderGuard alarm that morning, in case they were in a room and would not be able to see the Resident leave. When asked how the decision would be made to remove the alarm, the DNS stated the Shahbazim would decide. When the DNS was asked what Shahbazim did if the Resident was able to elope, she replied that would be an "unusual occurrence". However, the DNS stated the Resident tried to leave the facility on Mother's Day because she had been expecting her family to take her home. Review of Resident #8's medical record on 5/25-28/11 revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's medication regimen included mirtazapine and sertraline (antidepressants that can cause hallucinations and mood changes), and olanzapine (antipsychotic that can cause memory loss and mood changes). Review of the Resident's most recent Minimum Data Set assessment, a quarterly assessment dated [DATE], revealed the Resident had short and long-term memory problem and was moderately impaired in decision making ("decisions poor; cues/supervision required). Review of elopement assessments revealed the following: on 12/11/10 at 10:51 pm, "History of Elopement past 6 Mos. (months): 1 or 2 did go outside once in the past 90 days Shahbaz followed her out..." and on 3/5/11 at 4:54 pm, "History Elopement Past 6 Mos: 1 or 2." Review of the current care plan revealed that, although the resident had a history of [REDACTED]. On 5/25/11 at 7:45 pm, facility administration was notified that failing to ensure processes were in place to identify, evaluate, care plan, and reevaluate risks associated with potential elopements constituted an immediate jeopardy to Resident #8's health and safety. On 5/25/11 at 7:50 pm the facility abated the immediate jeopardy by placing a WanderGuard alarm on the Resident. .

Based on observation, interview, and record review the facility failed to: 1) Ensure the resident environment was free from hazardous equipment for 1 (#7) of 3 residents with wandering behaviors living in Raven Lodge, out of 8 sampled residents. This failed practice constituted an immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 5/23/11 at 1:20 pm. The immediate jeopardy was abated onsite; and 2) Ensure the safety of 1 resident (#8) with a history of potential elopement out of 8 residents residing in Lupine Lodge. This failed practice constituted an immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 5/25/11 at 7:45 pm. The immediate jeopardy was abated onsite. Findings: Unsecured Equipment Observations during the initial tour of Raven Lodge on 5/23/11 at 10:20 am revealed the door to Room 8 had a piece of yellow "Caution" tape draped from the top of the door frame. The door was unlocked and the room was unoccupied. Further observation revealed several large sheets of laminate-type flooring were on the floor. In addition, a utility knife with extra blades; 2 pair of industrial snippers, a DeWalt drill with a drill bit installed; and a caulking gun containing Color Flex2 were in the room. Observation in Raven Lodge on 5/23/11 at 10:32 am revealed Resident #7 was wandering up and down the hallway past Room 8. The Resident was holding a purse, and stated "I'm going to trash this." After wandering aimlessly, the Resident walked over to the dining room table and began picking up various items and setting them back down on the table. During an interview on 5/23/11 at 10:32 am, when asked about Resident # 7's wandering behavior, Shahbaz #8 confirmed the Resident did wander into other residents' rooms. Record review on 5/23-27/11 revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's most recent comprehensive Minimum Data Set assessment, an annual assessment dated [DATE], revealed Resident #7 was coded as having short and long-term memory loss and behavior symptoms that included rummaging 1-3 days per week. In addition, the Resident was coded as wandering, identified as placing the Resident "at significant risk of getting to a potentially dangerous place". Review of nurse's notes dated 12/20/10 and 3/11/11 revealed the Resident was observed wandering into other residents' room. At 10:42 am on 5/23/11, when the Contractor returned to Room #8, he was asked about the tools in the unsecured room. He replied the bedrooms in the Lodge did not lock. During an interview on 5/23/11 at 11:00 am with Physical Plant Service Staff #s 1 and 2, they were asked about the tools in Room 8. Staff #2 responded that he believed the equipment was locked up at night. When asked what information had been provided to the contactors regarding confused residents who wandered, Staff #2 replied this contracting company did a lot of work in health care facilities, including Providence facilities, so they should know what to do. During a second interview on 5/23/11, at 11:30 am, the Contractor stated the yellow caution tape used to be draped across the door but someone had removed it. The Contractor confirmed they had been leaving tools and other equipment in the rooms at night. When asked if the facility had provided information regarding safety or an orientation to the Lodge and residents, the Contractor replied they had not. During an interview on 5/23/11 at 1:18 pm, the Physical Plant Services Manager confirmed no training had been provided for the workers prior to working in the Lodges because this contracting company had been working in health care facilities for years. He stated the facility had no policy that addressed the safety of confused wandering residents but his expectation was that potentially dangerous equipment would be secured when unattended. On 5/23/11 at 1:20 pm facility administration was notified that leaving potentially harmful tools unsecured in a home with a Resident who was confused and who wandered constituted an immediate jeopardy to Resident # 7's health and safety. On 5/23/11 the facility abated the immediate jeopardy by removing Room 8's door handle (necessitating the use of a tool to open the door), so the room was secure. Potential Elopement Observation on 5/25/11 at 9:25 am revealed that the inner entry door to Raven Lodge was locked. After Shahbaz #8 opened the door, she was asked why the inner door was locked. The Shahbaz replied that earlier that day Resident #8 had been trying to leave the facility, so they placed a WanderGuard alarm (a device worn by a resident to help prevent elopement) in the window of the dining area, which locked the inner door. At 10:05 am on 5/25/11 the nurse for Raven Lodge, Licensed Nurse (LN) #4 was unable to open the inner door. She also questioned why the door was locked. At 10:15 am, when Resident #8 returned to her room, Shahbaz #8 removed the WanderGuard alarm from the window and said the Resident was "not going to leave now". During an interview on 5/25/11 at 5:40 pm the acting Director of Nursing Services (DNS) was asked about using a WanderGuard in Raven Lodge to keep Resident #8 from leaving. She replied that Resident #8 did not have a "strong" history of eloping, so staff would use the WanderGuard as a temporary measure to lock the Lodge. The DNS confirmed that she had given the ok for Raven Lodge staff to use the WanderGuard alarm that morning, in case they were in a room and would not be able to see the Resident leave. When asked how the decision would be made to remove the alarm, the DNS stated the Shahbazim would decide. When the DNS was asked what Shahbazim did if the Resident was able to elope, she replied that would be an "unusual occurrence". However, the DNS stated the Resident tried to leave the facility on Mother's Day because she had been expecting her family to take her home. Review of Resident #8's medical record on 5/25-28/11 revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's medication regimen included mirtazapine and sertraline (antidepressants that can cause hallucinations and mood changes), and olanzapine (antipsychotic that can cause memory loss and mood changes). Review of the Resident's most recent Minimum Data Set assessment, a quarterly assessment dated [DATE], revealed the Resident had short and long-term memory problem and was moderately impaired in decision making ("decisions poor; cues/supervision required). Review of elopement assessments revealed the following: on 12/11/10 at 10:51 pm, "History of Elopement past 6 Mos. (months): 1 or 2 did go outside once in the past 90 days Shahbaz followed her out..." and on 3/5/11 at 4:54 pm, "History Elopement Past 6 Mos: 1 or 2." Review of the current care plan revealed that, although the resident had a history of [REDACTED]. On 5/25/11 at 7:45 pm, facility administration was notified that failing to ensure processes were in place to identify, evaluate, care plan, and reevaluate risks associated with potential elopements constituted an immediate jeopardy to Resident #8's health and safety. On 5/25/11 at 7:50 pm the facility abated the immediate jeopardy by placing a WanderGuard alarm on the Resident. .