**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 1/2024, 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 . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 9/9/24 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 9/9/24 at 2:00 PM, in the food storage room, a frozen mushroom soup was labeled 4/2024, with no use by date. During an interview on 9/9/24 at 2:05 PM, [NAME] #1 stated the half and half and milk were opened today (9/9/24). 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 9/9/24 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 9/6/24 and no expiration date. During an interview on 9/11/24 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 9/9/24 at 3:30 PM, revealed: 1) Dry Pantry: 1- 1.3-ounce, Nutri Grain raspberry bar, manufacturer's expiration date was, 8/15/24. 1- 16-ounce, Custom Culinary, Low-Sodium Vegetable Base, manufacturer's expiration date was 7/23/24. 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- 1/2 Sandwich made of brown bread, Item PB&J, Prepared Date, 9/3, Use By, 9/6, 1- 16-ounce Custom Culinary, Low-Sodium Chicken Base, covered with Saran wrap, opened date 8/28/23 and expiration date was 2/28/24. 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 3/2024, 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 5/17/24, 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 1/18/ 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. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 . .

. 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. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 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. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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, [NAME] #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, [NAME] #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, [NAME] #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 [NAME] 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. [NAME] #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 [NAME] then picked up 2 potholders and removed a foil covered metal pan from the oven and set it on the counter. [NAME] #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, [NAME] #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 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 of malignant neoplasm of the breast, anxiety disorder, left upper extremity disorder, and bipolar 1 disorder. 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements.) 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 Parkinson's disease 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 injuries from his/her fall in the form of lacerations to his/her face and head. 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. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 Parkinson'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 . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 Risperidone (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 Risperidone 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 Clonazepam (psychotropic medication) 0.5 mg three times daily, PRN for anxiety. Review of this order showed the physician had reordered the Clonazepam 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 psychotropic 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 psychotropic 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 Zyprexa (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 Zyprexa 18 days. Review of the MAR for October 2021 it was documented the Resident was administered Lorazepam 25 days and Zyprexa 15 days. Review of the MAR for November 2021 it was documented the Resident received Lorazepam eight days and Zyprexa 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 Zyprexa 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. .