A list of the most recent deficiencies for Providence Seward Mountain Haven. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Develop a communication plan. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-14 | 2023-04-28 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-03-03 | 2023-04-17 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-03-03 | 2023-04-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-03 | 2023-04-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-03 | 2023-04-17 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-03 | 2023-04-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-03 | 2023-04-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-03 | 2023-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-14 | 2022-08-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-14 | 2022-08-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-12 | 2021-12-27 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-12 | 2021-12-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-12 | 2021-12-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-12 | 2021-12-27 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-12 | 2021-12-27 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-04-13 | 2021-04-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-06 | 2020-11-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-03-06 | 2020-11-17 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-03-06 | 2020-11-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-06 | 2020-11-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-03-06 | 2020-11-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-03-06 | 2020-11-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-06 | 2020-11-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-06 | 2020-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-06 | 2020-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-03-06 | 2020-11-17 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-03-06 | 2020-11-17 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2020-03-06 | 2020-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-06 | 2020-11-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-03-06 | 2020-11-17 | N |
