Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Seward Mountain Haven during CMS and state inspections, most recent first.
The facility failed to obtain and document informed consent for psychotropic medications before administration for multiple residents with dementia, Parkinson’s disease, and related behavioral and psychotic disturbances. In several cases, residents had OPA guardians or other representatives as medical decision-makers, yet there was no evidence that risks, benefits, alternatives, or treatment options for medications such as divalproex, valproic acid, olanzapine, quetiapine, pimavanserin, and antidepressants were discussed or that representatives were given an opportunity to choose among options. For one resident, consent for quetiapine was signed after the first dose had already been given. Staff interviews showed confusion about who was responsible for obtaining informed consent, when it should occur, and which medications required it, and leadership acknowledged that consents obtained via email were not consistently placed in the medical record and that consent audits were irregular, despite facility policies and resident rights documents requiring that residents or representatives be advised of psychotropic risks and benefits and that this be documented.
The facility failed to provide accurate information about the grievance officer and did not ensure residents could file grievances anonymously. The Resident Handbook listed an outdated grievance officer, and staff were unaware of the current officer. Most residents did not know how to file grievances, and the suggestion boxes intended for anonymous submissions were unlocked and improperly labeled.
A long-term care facility failed to report final investigation results to the State Agency within the mandatory period for five incidents, including a fall with a fracture, a resident left outside, pressure injuries, rough handling, and an abuse allegation. Delays ranged from one to three months, potentially placing residents at risk.
A resident with expressive aphasia and cognitive impairments was administered eye drops and topical medications in a public dining area by an LN, violating their right to privacy and dignity. The facility's policy and the DON's expectations were not followed, as medications other than oral should be administered in private unless the resident chooses otherwise.
A facility failed to provide written notice of its bed-hold policy to a resident and their representative during an emergency hospital transfer. The policy requires notification as soon as practical after such transfers, but staff interviews revealed a lack of awareness and adherence to this requirement. This oversight risked the resident losing their bed due to an extended hospital stay.
The facility failed to properly label and store medications and medical supplies for residents in the Eagle and Lupine lodges. Expired supplies were found in the Lupine Lodge, and insulin pens were improperly stored without prescription labels in medication carts. This practice was acknowledged by staff and contradicted the facility's policy, posing a risk of medication errors.
The facility failed to ensure food safety for 18 residents by not properly labeling opened food items in the Lupine and Raven lodges' kitchens. Surveyors found several items without opened or use-by dates, and some expired items were also present. Staff interviews revealed a lack of adherence to labeling guidelines, potentially placing residents at risk of receiving contaminated food.
CNAs failed to change soiled gloves and perform hand hygiene during resident care, violating infection control protocols. Despite training, CNAs moved from dirty to clean tasks without proper glove changes or hand hygiene, increasing infection risk.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to administration, thereby failing to ensure residents or their representatives were informed in advance of the risks, benefits, alternatives, and options for treatment. For Resident #1, who had severe dementia with psychotic disturbance, anxiety disorder, and depressive disorder, the record showed extensive use of multiple psychotropic medications, including divalproex, lorazepam, olanzapine, quetiapine, sertraline, and trazodone over a defined period. The resident had an Office of Public Advocacy (OPA) guardian as medical decision-maker, yet there was no documented informed consent for any of these medications. Emails to the guardian referenced that Depakote and other psychotropics had been ordered or adjusted, but did not include information on risks, benefits, alternatives, or options, nor did they document that the guardian was given an opportunity to choose a preferred option. The guardian later stated the facility had never reviewed risks, benefits, alternatives, or options for any medications and that such information would have guided decision-making. For Resident #3, who had vascular dementia and cerebrovascular disease and also had an OPA guardian, the medical record showed long-term administration of valproic acid and a period of mirtazapine use, totaling hundreds of psychotropic medication administrations. The record contained no documented informed consent for these medications. A progress note indicated that a licensed nurse was unable to reach the resident’s representative and mailed a copy of notes, including the addition of mirtazapine, but there was no further documentation of efforts to contact the representative to discuss medications or obtain informed consent. The facility was unable to provide any proof of informed consent for Resident #3’s psychotropic medications, and the guardian similarly stated that information on risks and benefits would have guided decision-making. For Resident #4, who had Parkinson’s disease with dyskinesia, dementia due to Parkinson’s disease with behavioral disturbance, hallucinations, and Lewy body dementia with psychotic disturbance, the record showed an order and ongoing administration of pimavanserin, an antipsychotic, over approximately 90 days. The resident had a representative who made medical decisions, but there was no documented informed consent for this psychotropic medication, and the facility could not provide any proof when requested. For Resident #5, diagnosed with dementia with behavioral disturbance and Parkinson’s disease, quetiapine was ordered and first administered before the facility obtained a signed Psychotropic Risk/Benefits Verification of Informed Consent form; the consent was dated one day after the first dose was given. This demonstrated that consent was not obtained prior to initial administration. Interviews with nursing staff and leadership revealed confusion and inconsistency regarding responsibility for obtaining informed consent, when it should be obtained, and where it was documented. One licensed nurse believed physicians were ultimately responsible for obtaining consent and was unsure where signed consents were stored. Another nurse did not know who was responsible, when to obtain consent, or how to verify its presence before administering a new medication, and believed only antipsychotics required consent. A third nurse assumed that if a physician wrote an order, informed consent had already been obtained, and identified psychotropics and antipsychotics as requiring consent that included discussion of risks and benefits. The DON and LTC nurse manager stated that bedside nurses were trained to obtain informed consent before the first dose of medications needing consent and that the facility did not obtain new informed consent for psychotropics if a resident was already taking the same medication on admission, assuming the resident already knew the risks and benefits. The LTC nurse manager also stated that consents were sometimes obtained via email to representatives or guardians, but copies of those emails were not placed in the medical record, and audits of consents had not been done regularly. These practices conflicted with the facility’s resident rights document and its psychopharmacological drug use policy, both of which required that residents or their representatives be advised of potential risks and benefits of psychotropic medications and that this be documented.
Grievance Process Deficiency
Penalty
Summary
The facility failed to ensure accurate information regarding the grievance officer was available to residents and did not provide a means for residents to file grievances anonymously. The Resident Handbook listed an outdated grievance officer, GO #1, while the current grievance officer was GO #2, the Quality Improvement Coordinator (QIC). Interviews with staff revealed a lack of awareness about the current grievance officer, with some staff members incorrectly identifying the social worker or other unknown staff as the grievance officer. The policy and procedure for resident complaints required the facility to provide contact information for the grievance officer, but this was not effectively communicated to residents or staff. Additionally, the facility did not ensure that residents were aware of how to file grievances anonymously. During a Resident Council meeting, most residents were unaware of the grievance filing process, and the QIC was unaware of this lack of knowledge. The facility's policy allowed for anonymous submissions through a box in each lodge, but observations revealed that these boxes were labeled as suggestion boxes and were unlocked, which may have contributed to the residents' lack of awareness and confidence in the anonymity of the grievance process.
Delayed Reporting of Investigation Results in LTC Facility
Penalty
Summary
The facility failed to report the final investigation results to the State Agency for five Facility Reported Incidents (FRIs) within the mandatory reporting period. This deficiency involved several residents and incidents, including a fall resulting in a fracture, a resident left outside unattended, multiple pressure injuries, rough handling by a caregiver, and an allegation of physical abuse. The incidents were not reported within the required five-day period, with delays ranging from one month to three months. Resident #5 experienced a fall that resulted in a left femur fracture, which required hospitalization and surgery. The initial report was sent to the State, but the final report was completed over a month after the incident, exceeding the five-day reporting requirement. Similarly, Resident #19 was found outside in the snow without supervision, and the final report was submitted three months after the incident. Resident #22 had multiple pressure injuries, and the final report was delayed by nearly three months. Resident #27 reported rough handling by a CNA, and although no harm was found, the final report was submitted two months after the incident. Resident #32 alleged physical abuse by a CNA, but the investigation found no evidence of harm. The final report for this incident was submitted 13 days after the occurrence. These delays in reporting final investigation results to the State Agency demonstrate a failure to comply with mandatory reporting requirements, potentially placing residents at risk.
Failure to Ensure Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure respect and dignity for a resident during the administration of topical medications. A Licensed Nurse (LN) applied eye drops and topical medications to a resident in a public dining area, which was visible to other residents and staff. This action was observed during a survey, and it was noted that the resident had expressive aphasia and cognitive impairments, making it difficult for them to communicate effectively. The resident's care plan highlighted these communication challenges, indicating a need for careful consideration of their privacy and dignity. The Director of Nursing (DON) confirmed that the expectation was for medications, other than oral ones, to be administered in the resident's room to ensure privacy unless the resident chose otherwise. The facility's policy also supported this practice, stating that medications by any other route than oral should not be given at the dining room table. Despite these guidelines, the LN administered the medications in a public setting, thereby failing to uphold the resident's right to privacy and dignity as outlined in the facility's resident handbook.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to a resident and their representative upon an emergency transfer to the hospital. This deficiency was identified during a record review and interviews, which revealed that the facility did not inform the resident or their Durable Power of Attorney (DPOA) about the bed-hold policy when the resident was sent to the emergency room for evaluation. The facility's policy requires that residents and their representatives be informed of the bed-hold guidelines as soon as practical after an emergency hospital transfer, but this was not done in this case. Interviews with facility staff indicated a lack of awareness and adherence to the bed-hold policy. A licensed nurse (LN #3) was unaware of the policy, and another nurse (LN #11) stated that the bed-hold form should have been included in the packet sent with the resident to the hospital. Additionally, the social services staff member (SS #2) acknowledged that they should have contacted the resident's representative to discuss the bed-hold policy but failed to do so. This oversight placed the resident at risk of losing their bed at the facility due to an extended hospital stay.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
The facility failed to ensure that drugs and medical supplies were labeled and stored according to acceptable professional principles for 19 residents in the Eagle and Lupine lodges. Specifically, expired medical supplies were found in the Lupine Lodge's medication room and medical supply storage room. These included a tube of toothpaste and adult aerosol masks with past expiration dates, as well as multiple expired hydrofiber dressings with silver. Additionally, the facility did not properly label and store insulin pens in the medication carts of both the Eagle and Lupine lodges. Insulin pens were found rolling around in drawers without being in their original dispensing boxes or secured in zipped bags. The only identification on these pens was handwritten on tape, lacking proper pharmacy prescription labels. This practice was acknowledged by the licensed nurse and the Director of Nursing, who stated that insulin pens should be stored in their original containers with pharmacy labels. The pharmacist confirmed that medications should be dispensed in the manufacturer's packaging with a prescription label, and that the current practice of storing insulin pens without proper labeling and security was not sanitary and could lead to medication errors. The facility's policy also required medications to be stored separately for each resident and in the packaging received from the pharmacy, which was not adhered to in this case.
Food Safety Deficiency in Facility Kitchens
Penalty
Summary
The facility failed to ensure food safety for 18 residents who received food from the Lupine and Raven lodges' kitchen. During an initial tour of the Raven Lodge kitchen, surveyors observed several opened food items in the refrigerator, such as half and half and milk, without any opened or use-by dates. Additionally, opened thickeners were found on the counter without proper labeling. In the food storage room, a frozen mushroom soup was labeled with a date but lacked a use-by date. Interviews with staff revealed a lack of adherence to labeling guidelines, as they stated that certain items were not labeled due to their fast usage. At the Lupine Lodge kitchen, similar issues were noted, including opened food items like beef base, honey, and bread slices without opened or expiration dates. Expired food items were also found, such as a Nutri Grain bar and a low-sodium vegetable base. The facility's food storage guidelines and policy required labeling of opened foods with 'opened on' and 'use by' dates, but these were not followed. The USDA and FDA guidelines were referenced, indicating the need for proper labeling to ensure food safety, but the facility did not comply, potentially placing residents at risk of receiving contaminated food.
Inadequate Infection Control Practices by CNAs
Penalty
Summary
The facility failed to ensure proper infection control and prevention practices during the care of an unsampled resident. During an observation, two CNAs were seen performing care on the resident without changing soiled gloves before moving from dirty to clean areas. Specifically, CNA #2 applied lotion and deodorant to the resident's arm and armpit without changing gloves after cleaning the resident's perineal area. Similarly, CNA #1 removed a foam dressing, cleaned the resident's buttocks, and handled soiled washcloths without changing gloves or performing hand hygiene. Additionally, both CNAs continued to perform tasks such as dressing the resident and using a Hoyer lift without changing their soiled gloves or performing hand hygiene between glove changes. The facility's hand hygiene policy and CDC guidelines emphasize the importance of hand hygiene before and after glove use, which was not adhered to in this instance. The infection preventionist confirmed that CNAs were trained on hand hygiene, yet the observed practices did not reflect this training.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Providence Seward Mountain Haven.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.