Denali Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairbanks, Alaska.
- Location
- 1510 19th Avenue, Fairbanks, Alaska 99701
- CMS Provider Number
- 025020
- Inspections on file
- 16
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Denali Center during CMS and state inspections, most recent first.
During a quarantine due to an Influenza outbreak, the facility failed to provide residents with clear instructions on filing grievances. The grievance box was located outside the administrator's office, inaccessible to residents confined to their units. Multiple residents expressed confusion about the grievance process and fear of retaliation. Staff interviews revealed that grievances were typically handled by staff rather than through the formal grievance box. The facility's grievance procedure documents lacked clear instructions on filing grievances, and the administrator acknowledged the inaccessibility of the grievance box during the lockdown.
The facility failed to properly store drugs and medical supplies, resulting in the presence of expired items in various medication and supply rooms. Expired supplies, including medical and nutritional products, were found in the Tamarack and Birch Medication Rooms and the Denali Center BLS Cart. Interviews revealed a lack of oversight and responsibility among staff, with expired items not being discarded or returned as required. Additionally, the absence of written policies for dietary product storage contributed to the deficiency.
The facility failed to adhere to food safety standards, with numerous expired and unlabeled food items found in storage and improper hand hygiene practices observed during food preparation. Staff did not follow established policies, leading to potential contamination risks.
Nutrition service staff failed to follow proper hand hygiene practices during food preparation, risking cross-contamination and infection spread. Observations showed staff changing gloves without washing hands and handling both raw and cooked food without proper hygiene, violating facility policies and FDA guidelines.
The facility failed to support resident choice in activities, affecting three residents with various medical conditions. Due to lockdown measures, residents were unable to participate in preferred activities like bingo and church services, with no alternatives provided. Staff interviews confirmed that activities were suspended to prevent close contact, and virtual options were not considered.
The facility failed to monitor and evaluate the use of assistive devices as physical restraints for two residents, leading to unnecessary restraint. One resident with dementia and Parkinson's disease was unable to remove a wheelchair belt independently, and another resident with failure to thrive and schizophrenia was similarly restrained with a belt alarm. The facility did not document evaluations of the residents' ability to remove the belts, violating its policy on restraints.
The facility failed to provide scheduled showers or baths to two residents, as outlined in their care plans. One resident, with morbid obesity and hemiplegia, did not receive a shower for nine days, while another, with heart disease and cerebral edema, experienced gaps of up to 13 days without a documented bath. Staff claimed bed baths were given but were not documented, resulting in a failure to maintain personal care and hygiene.
The facility failed to obtain informed consent and conduct risk assessments for bed rail use for several residents, including those with cerebral palsy, fractures, diabetes, dementia, and schizophrenia. Observations showed residents with raised bed rails without understanding the reason, and staff confirmed the absence of necessary documentation. This deficiency potentially placed residents at risk of falls and entrapment.
Two residents experienced a lack of dignified care in a facility. One resident with COPD and a history of stroke was denied assistance with an evening snack by a CNA, leading to feelings of discrimination. Another resident with paraplegia and other conditions waited over an hour for toileting assistance, despite multiple staff being informed of the need. These incidents reflect a failure to provide care with respect and dignity, as required by the facility's policies.
A resident with COPD and a history of stroke reported feeling discriminated against after a CNA refused to assist with an evening snack. The facility failed to report and investigate this mistreatment within the required timeframe, as mandated by their policy. The incident was not communicated to the Administrator or investigated, highlighting a lapse in following established procedures for handling allegations of mistreatment.
A resident with COPD and a stroke reported mistreatment by a CNA, who refused to provide a snack and made a derogatory comment. Despite the resident informing a nurse, the facility failed to investigate or report the incident to the State agency, as required by their policy.
A resident with dementia and Parkinson's disease was found alone in a wheelchair with a seat belt they could not remove due to tremors, contrary to their care plan. Staff interviews revealed a lack of documentation and awareness regarding the resident's ability to remove the seat belt, placing the resident at risk for inadequate care.
A facility failed to maintain an accurate medical record for a resident, omitting a diagnosis of bipolar disorder from the EHR and MDS. Despite the Medical Director's note indicating the condition, it was not updated in the records due to a lack of policy and procedure for coding diagnoses. This oversight risked inconsistencies in the resident's treatment and care.
A resident with dementia and a history of elopement attempts left the facility undetected due to staff failing to conduct regular safety checks and walking rounds. The resident's wander guard device was not functioning due to a dead battery, which was not checked as per facility policy. The staff assumed the resident was elsewhere in the facility, leading to a significant delay in realizing the resident was missing.
Failure to Provide Accessible Grievance Process During Quarantine
Penalty
Summary
The facility failed to ensure residents were provided with clear instructions on how to file a grievance during a quarantine due to an Influenza outbreak. Residents were unable to access the grievance box, which was located outside the administrator's office, away from the quarantined units. This situation was confirmed during a Resident Council meeting where multiple residents expressed confusion about the grievance process and fear of retaliation if they complained about their care. Observations during the survey period revealed that all units were quarantined, and there were no indications on how to file a grievance within the units. The grievance box was located by the front entrance of the facility, inaccessible to residents confined to their units. Interviews with staff, including Resident Care Coordinators, indicated that grievances were typically handled by staff members rather than through the formal grievance box, which was not easily accessible during the lockdown. The facility's grievance procedure documents did not provide clear instructions on how to file a grievance or where to deposit the grievance form. The administrator acknowledged the location of the grievance box and the lack of additional boxes in the units, citing concerns about spreading the virus and managing multiple boxes. Despite these measures, the facility did not ensure that residents could file grievances without fear of discrimination or reprisal, as required by their policy.
Improper Storage of Drugs and Medical Supplies
Penalty
Summary
The facility failed to properly store drugs and medical supplies, leading to the presence of expired and potentially non-sterile items in various medication and supply rooms. Observations revealed expired medical supplies such as BD ChloraPrep applicators, distilled vinegar, Nicotrol Inhaler cartridges, children's multivitamins, and surgical gloves, among others. These items were found in the Tamarack and Birch Medication Rooms, as well as the Denali Center BLS Cart. Interviews with Resident Care Coordinators (RCCs) and a pharmacist confirmed that expired supplies should have been discarded or returned to the pharmacy, but this was not consistently done. The pharmacist noted that some home medications, like the Nicotrol Inhalers, were not monitored by the pharmacy department, contributing to the oversight. Additionally, the facility's procedures for checking and restocking emergency equipment and medical supplies were not adequately followed. The Denali Center BLS Cart contained expired Kerlix bandage rolls, and the facility's Emergency Equipment Cart log indicated that checks were not performed as required. The Birch Medication Room also contained opened and expired supplies, such as sodium chloride injection bags and pulse oximeter sensors. Interviews with RCCs and Nutrition Services staff revealed a lack of responsibility and oversight in ensuring that expired nutritional supplements and dietary products were removed from storage. The absence of written policies and procedures for the storage of dietary products further contributed to the deficiency.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that potentially hazardous foods were stored, labeled, and prepared in accordance with professional standards for food safety. During an observation of the main kitchen and storage areas, numerous expired food items were found, including single-serving packets of apple cider, sweet and sour sauce, soy sauce, canned fruits, and breakfast bars. Additionally, several food items in the dry storage and refrigerator were not labeled or dated, including macaroni salad, sliced apples, and various condiments. The Culinary Director was unable to provide an explanation for the lack of labeling and dating on these products. In the Fireweed Cafe dining refrigerator, expired yogurt and unlabeled containers of macaroni salad and apple slices were observed. The Nutrition Service staff indicated that these items were prepared for same-day use, but they were not labeled or dated. In the walk-in freezer, several food items were found in open or unlabeled containers, including plant-based patties, pasta noodles, hotdog buns, biscuits, and various baked goods. The Culinary Director and Nutrition Service staff stated that frozen foods were not dated because they believed the quality, not safety, was affected over time. During food preparation and plating observations, staff failed to perform proper hand hygiene between glove changes. Staff members were seen handling food with the same gloves used for different tasks, including cracking raw eggs and serving cooked food, without washing their hands. This practice was contrary to the facility's policy, which required hand hygiene between glove changes to prevent contamination. The facility's policies on food safety and sanitization, food preparation, and job descriptions for food service workers and cooks emphasized the importance of following food handling regulations, which were not adhered to in these instances.
Inadequate Hand Hygiene Practices in Food Preparation
Penalty
Summary
The facility failed to ensure that nutrition service staff adhered to proper hand hygiene practices during food preparation, which placed all residents at risk for cross-contamination and the spread of infectious diseases. Observations revealed that a nutrition service staff member, identified as NS #1, did not perform hand hygiene between glove changes while preparing supplemental shakes and pureed bananas. NS #1 was seen changing gloves without washing hands after retrieving supplies from another room. Another staff member, NS #2, was observed cooking and preparing food with gloved hands, wiping them on a towel, and handling both raw and cooked food without changing gloves or performing hand hygiene. The facility's policies on food safety and sanitization, as well as food preparation, require staff to wash their hands before starting work in the kitchen and after using their hands in an unsanitary way. The U.S. Food and Drug Administration's Food Code also mandates that food employees clean their hands before engaging in food preparation and when switching between handling raw and ready-to-eat food. Despite these guidelines, the staff's failure to follow proper hand hygiene practices was evident, as they continued to handle food without washing their hands or changing gloves appropriately, leading to a deficiency in infection prevention and control.
Failure to Support Resident Choice in Activities
Penalty
Summary
The facility failed to ensure that three residents were given the opportunity to make choices about aspects of their lives that were significant to them, specifically in relation to participating in activities. Resident #19, who has diagnoses including morbid obesity, major depressive disorder, anxiety, and hemiplegia, expressed dissatisfaction with the lockdown measures that prevented participation in activities like bingo and socializing. The resident's care plan indicated a need for participation in activities of choice and social interaction, but these needs were not met due to the facility's restrictions. Resident #22, diagnosed with anxiety, aphasia, hemiplegia, and major depressive disorder, also reported being unable to attend activities due to the lockdown, with no alternative activities offered for church services. Similarly, Resident #25, with conditions such as morbid obesity, COPD, hypertensive heart disease, type 2 diabetes, and major depressive disorder, expressed frustration over the inability to attend church or move freely within the facility. The resident council confirmed that no virtual options for religious services were provided. Interviews with facility staff, including the Medical Director and Activities Assistant, revealed that activities were suspended by default to prevent close contact, and alternative options like virtual church services were not considered.
Failure to Monitor and Evaluate Use of Physical Restraints
Penalty
Summary
The facility failed to properly monitor and evaluate the use of assistive devices as physical restraints for two residents, leading to a deficiency in ensuring residents' freedom from unnecessary restraints. Resident #31, diagnosed with dementia and Parkinson's disease, was observed wearing a belt attached to a wheelchair, which the resident could not remove independently. The Resident Care Coordinator (RCC) and Director of Nursing (DON) were unaware of any evaluation confirming the resident's ability to remove the belt, despite the resident's care plan indicating the need for independent removal of the seatbelt. Similarly, Resident #61, with diagnoses including failure to thrive and schizophrenia, was found with a belt attached to a wheelchair that the resident could not remove. The belt was equipped with an alarm that sounded when released. The Certified Nursing Assistant (CNA) and RCC were unaware of any documented evaluation verifying the resident's ability to remove the belt independently. The facility's policy states that a seat belt is considered a restraint if the resident cannot remove it easily, which was the case for Resident #61. The facility's failure to assess and document the residents' ability to remove the seat belts independently resulted in the use of physical restraints without proper justification. This oversight placed the residents at risk of unnecessary restraint and potential physical injury, as the facility did not adhere to its policy requiring that residents be free from physical restraints unless necessary for medical treatment.
Failure to Provide Scheduled Showers or Baths
Penalty
Summary
The facility failed to provide activities of daily living (ADLs) to two residents, specifically in the form of showers or baths, as outlined in their individualized care plans. Resident #19, who was admitted with diagnoses including morbid obesity and hemiplegia, was scheduled to receive showers twice a week. However, a review of the facility's records revealed that Resident #19 had not received a shower or bath for nine days, with no documentation of any alternative form of bathing provided. Interviews with staff confirmed the lack of documentation and adherence to the bathing schedule. Similarly, Resident #67, who was dependent on assistance for bathing due to conditions such as atherosclerotic heart disease and cerebral edema, did not receive showers or baths as per the care plan. The facility's records showed significant gaps between bathing sessions, with periods extending up to 13 days without a documented shower or bath. Although staff claimed that bed baths were provided when showers were not possible, these were not documented, leading to a failure in maintaining the residents' personal care and hygiene as required by their care plans.
Failure to Obtain Consent and Conduct Bed Rail Assessments
Penalty
Summary
The facility failed to obtain informed consent and conduct accurate risk and benefit assessments for the use of bed rails for several residents. This deficiency was identified during a review of records, observations, and interviews with residents and staff. Specifically, the facility did not have documented physician orders or informed consent for the use of bed rails for five residents, including those with conditions such as cerebral palsy, fractures, diabetes mellitus, dementia, Parkinson's disease, failure to thrive, and schizophrenia. Observations revealed that residents had bed rails raised without understanding the reason, and there was no evidence of bed rail assessments in their medical records. For instance, one resident with cerebral palsy had multiple bed rails raised without a clear explanation or consent, and another resident with a fracture and diabetes had all side rails raised without understanding why. Similar issues were noted for other residents, including those with dementia and schizophrenia, who also had raised bed rails without documented assessments or consent. Interviews with staff, including the Resident Care Coordinator and the Director of Nursing, confirmed the absence of bed rail assessments and informed consent documentation. The facility's policy on bed safety assessment, which requires interdisciplinary participation and documentation of risks and benefits, was not followed. This failure to adhere to policy and obtain necessary consents and assessments potentially placed residents at risk of falls, entrapment, and other preventable accidents.
Failure to Provide Dignified Care for Residents
Penalty
Summary
The facility failed to provide care with respect and dignity for two residents, leading to deficiencies in their quality of life. Resident #50, who has COPD and a history of stroke, reported an incident where a CNA refused to assist with an evening snack, telling the resident to get it themselves. This interaction left the resident feeling discriminated against. Despite the nurse eventually providing the snack, the Resident Care Coordinator acknowledged that no investigation was conducted regarding the alleged mistreatment, which was a missed opportunity to address the issue. Resident #27, diagnosed with paraplegia, neurogenic bladder, anemia, anxiety disorder, and depression, experienced a significant delay in receiving toileting assistance. After pressing the call light for help, the resident waited over an hour for assistance, during which time multiple staff members were informed of the need but did not provide timely help. The resident expressed concerns about staffing levels and the responsiveness of staff to call lights. The delay resulted in the resident sitting in a soiled state, which was confirmed by the surveyor's observation of a fecal odor in the room. The facility's policies on abuse and neglect, as well as resident rights, emphasize the importance of providing care with dignity and respect. However, in both cases, the facility's actions and inactions failed to uphold these standards, as evidenced by the lack of immediate response to Resident #27's call for assistance and the inappropriate response to Resident #50's request for a snack. These deficiencies highlight a failure to ensure that residents are treated with the respect and dignity they are entitled to under the facility's policies.
Failure to Report and Investigate Resident Mistreatment
Penalty
Summary
The facility failed to implement its policies and procedures to prevent mistreatment of residents, specifically in the case of a resident with COPD and a history of stroke. The resident, who had an intact cognitive status, reported an incident where a CNA refused to assist in obtaining an evening snack, making the resident feel discriminated against. This incident was not reported to the Administrator within the required 24-hour timeframe, as the events did not involve abuse, but rather mistreatment. The facility's policy mandates that any employee who suspects mistreatment must report it immediately to the Administrator or Director of Nurses and to local law enforcement within 24 hours. However, the Resident Care Coordinator acknowledged that no investigation was conducted regarding the alleged mistreatment, identifying it as a missed opportunity. The Administrator was unaware of the incident, and the Medical Director also confirmed a lack of awareness and investigation prior to the survey. The facility's policy outlines the necessity of investigating all allegations of abuse and mistreatment, ensuring residents are protected during investigations, and reporting findings to the appropriate state agencies. Despite these requirements, the facility did not adhere to its policy, as the incident involving the resident was neither investigated nor reported, failing to protect the resident from potential further mistreatment.
Failure to Investigate and Report Alleged Mistreatment
Penalty
Summary
The facility failed to investigate an alleged report of mistreatment involving a resident who had been admitted with diagnoses including COPD and a stroke. The resident, who had an intact cognitive status, reported that a CNA refused to provide an evening snack and made a derogatory comment, which the resident felt was discriminatory. Despite the resident informing a nurse about the incident, no investigation was conducted, and the allegation was not reported to the appropriate authorities. Interviews with facility staff, including the Resident Care Coordinator and the Administrator, revealed that they were either aware of the incident but did not act or were not informed at all. The Medical Director also stated he was unaware of the allegations prior to the survey. The facility's policy mandates that all allegations of abuse must be investigated and reported to the State agency within five working days, which was not adhered to in this case.
Failure to Update Care Plan for Resident with Assistive Device
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident with assistive seat belt devices accurately reflected the resident's current status and care needs. The resident, who was admitted with dementia and Parkinson's disease, was observed sitting alone in a wheelchair with a seat belt that they could not remove independently due to bilateral upper extremity tremors. Despite the care plan indicating that the resident should not be left alone in a wheelchair and should be able to remove the Velcro seatbelt independently, the resident was found alone and unable to remove the belt. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's ability to remove the seat belt. A CNA was unaware if the resident could remove the belt independently, and the Resident Care Coordinator admitted there was no documented seat belt evaluation. The Director of Nursing was uncertain if an evaluation had been completed, despite the care plan's requirements. This oversight placed the resident at risk for inadequate care and potential injury.
Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, which resulted in incomplete documentation of the resident's medical conditions. The resident, who was admitted with diagnoses including generalized anxiety disorder, heart failure, and chronic kidney disease, also had a documented history of bipolar disorder with auditory hallucinations. However, this diagnosis was not consistently recorded in the resident's electronic health record (EHR) or the Minimum Data Set (MDS), which is a federally required nursing assessment. The omission of bipolar disorder from the active diagnosis list in the EHR and MDS was confirmed during interviews with the MDS Coordinator and the coder responsible for updating the diagnosis list. The coder stated that diagnoses were updated based on the most recent physician progress notes, which were reviewed on specific days of the week. Despite the Medical Director's progress note indicating the presence of bipolar disorder, this diagnosis was not reflected in the resident's EHR. The facility lacked a policy and procedure for the coding of medical diagnoses, which contributed to the oversight. This failure to accurately document the resident's medical condition placed the resident at risk for inconsistencies in treatment and care provided.
Resident Elopement Due to Inadequate Safety Checks
Penalty
Summary
The facility failed to adhere to its standards of care expectations, specifically in conducting regular resident location and safety checks, known as walking rounds, for one resident. This deficiency resulted in the staff being unaware of the resident's elopement from the facility for an extended period. The resident, who had a history of dementia, cardiovascular accident with hemiplegia, seizures, and chronic alcohol use, was known for repeated attempts to leave the facility seeking alcohol. Despite being equipped with a wander guard device, the resident managed to leave the facility undetected. On the day of the incident, the facility was fully staffed, yet the nursing staff did not perform their duties according to the established standards of care. The clinical report at shift change was not completed due to attending to another resident's fall, and the walking rounds at this shift change were also not conducted. Furthermore, the two-hour walking rounds expected throughout the evening shift were not completed for the resident. Interviews with the staff revealed an assumption that the resident was elsewhere in the facility, as they often roamed. Additionally, the facility's policy required a daily safety check of the wander guard device to ensure it was functioning properly. However, this check was not documented as completed on the day before or the day of the elopement. When the resident was returned to the facility, it was discovered that the wander guard's battery was dead, which prevented it from triggering the sensor at the door during the resident's elopement. The facility's investigation confirmed that the staff knew of the rounding expectations but failed to follow them.
Latest citations in Alaska
A resident with ESRD and dependence on hemodialysis did not receive post-dialysis care according to physician orders, the care plan, and facility policy. The post-dialysis pressure dressing on the AV fistula was not documented as removed within the ordered timeframe, despite dialysis center instructions specifying timely removal. Although an LN later reported that the access site was bleeding and a dressing change was performed, the TAR documented the site as clear and nursing notes did not reflect any dressing change. Required shift assessments of the fistula site for bleeding, redness, and tenderness were not accurately documented, and there was no evidence that the physician was notified of the bleeding access site, contrary to facility policy and referenced CDC dialysis safety standards.
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 maintain sufficient RN, LPN, and CNA staffing levels as defined in its own facility assessment, particularly on weekends, and frequently relied on float staff to cover cottages without regularly assigned nurses. Staff and a resident reported that only one nurse and one CNA sometimes covered an entire cottage, that CNAs from other cottages had to pick up assignments when someone called in, and that staff shortages caused rushing and concerns about care. One resident with quadriplegia, fully dependent for bathing and preferring showers, missed multiple scheduled showers over several weeks and instead received bed baths or no documented hygiene care, and reported long call-light response times and staff declining small assistance due to being too busy. Another resident with multiple sclerosis and functional quadriplegia, dependent on staff and an overhead lift for transfers, was not consistently gotten out of bed on the days specified in their care plan and grievance resolution, and reported that requests to get up were often denied or deferred because staff said they were shorthanded.
A resident with multiple medical and psychiatric diagnoses, under a full court-appointed guardianship granting the guardian authority over medical and mental health treatment, was sent to a behavioral health consultation without documented notification to the guardian. The consultation report noted the resident was unescorted, that there was documentation of a guardian/POA, and that the resident could not state why they were there, with a recommendation to obtain guardian contact. The Administrator and DON confirmed there was no documented guardian notification, and although the AA reported that transportation was provided and that the resident’s recent BIMS showed intact cognition, there was no chart documentation that the guardian had been informed of or consented to the mental health appointment.
Two residents did not receive ADL services as assessed and care planned. A resident with quadriplegia, fully dependent on staff and preferring showers, was care planned for twice-weekly showers using a Carendo chair, but logs and interview showed prolonged gaps without showers and missed scheduled shower days, with staff citing CNA shortages and long call-light response times. Another resident with multiple sclerosis and functional quadriplegia, dependent on staff for bed-to-chair transfers, had a care plan and CNA tasks specifying transfers to a chair multiple times per week, and had previously expressed concerns and filed a grievance about limited opportunities to get out of bed; however, task logs showed the resident was either not gotten up or only once per week over several weeks, and the resident reported staff often declined requests to get up due to staffing and workload.
Two residents were discharged without adequate planning, resulting in unsafe and inappropriate transitions. One was sent home to an inaccessible and unsafe environment without necessary support or services, leading to distress, a fall, and reliance on unplanned third-party assistance. Another was discharged despite unresolved behavioral and cognitive issues, without required mental health referrals or involvement of their representative, causing distress and confusion. The facility lacked documented discharge planning standards and failed to coordinate essential post-discharge care.
A resident with dementia, depression, anxiety, and other complex conditions was admitted without the PASRR Level II report being available or reviewed. The facility did not initiate specialized mental health services as required, delayed updating the care plan, and discharged the resident without addressing PASRR-identified needs or following recommended discharge options. This resulted in untreated behavioral symptoms and increased psychotropic medication use.
A resident with complex medical needs developed multiple pressure ulcers and infections due to the facility's failure to provide timely and consistent wound care interventions, delayed care planning, poor documentation of noncompliance, and lack of coordination for higher-level wound care referrals. Discrepancies between wound care provider recommendations and actual treatment orders, as well as improper antibiotic administration in relation to dialysis, contributed to persistent wound infection and ultimately led to hospitalization with sepsis and death.
Systemic failures in the QAPI program led to ongoing deficiencies in staffing, grievance procedures, activities, medication management, and therapy services. Residents experienced long wait times for assistance, were not properly informed about grievance processes, and were not consistently offered activities as documented in their care plans. Incomplete narcotic count documentation and lapses in therapy services further contributed to suboptimal care.
Two residents did not receive care according to physician orders and care plans. One resident with hypertension and heart failure had daily vital signs ordered but only had them documented twice over several months. Another resident with skin breakdown risk had orders for offloading boots and wound care that were not implemented, as observed during the survey. Facility policies required adherence to these orders and care plans.
Failure to Follow Post-Dialysis Orders and Document AV Fistula Complications
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related treatment and care in accordance with physician orders, the resident’s care plan, and facility policy for one resident dependent on hemodialysis with ESRD and PVD. Physician orders and the MAR directed that the post-dialysis pressure dressing on the resident’s AV fistula be removed after a specified number of hours, and dialysis communication from the dialysis center reiterated that the fistula dressing must be removed within a defined timeframe to prevent clotting or narrowing of the AV graft. Record review showed no documentation that the post-dialysis dressing was removed within the ordered timeframe, and there was no indication on the MAR or in nursing progress notes that a dressing change was performed during the relevant dates. The facility also failed to assess, document, and communicate the condition of the dialysis access site as ordered and per policy. The care plan required daily checks and dressing changes at the access site with documentation and monitoring for signs and symptoms of complications, and the TAR included an order to assess the fistula site every shift for clarity, tenderness, redness, and bleeding. A nurse reported that upon the resident’s return from dialysis, the access site was bleeding and a dressing change was performed, but the TAR documentation for that shift indicated the site was “clear,” and nursing progress notes contained no record of a dressing change. Additionally, despite facility policy requiring monitoring for complications and immediate physician notification for bleeding, the medical record contained no evidence that the physician was notified about the post-dialysis bleeding AV fistula. CDC dialysis safety guidelines cited in the report state that standards of care require reassessment of the access site after dressing removal for bleeding, redness, or swelling, with accurate documentation and timely communication of findings, which was not demonstrated in this case.
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.
Insufficient Nursing Staff Leading to Missed ADLs and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff, including CNAs and licensed nurses, to meet residents’ needs as established in its own facility assessment. The assessment specified minimum staffing levels of 6–8 licensed nurses on day shift, 5–7 licensed nurses on night shift, 8–10 CNAs on day shift, and 7–8 CNAs on night shift. Review of staffing schedules for December 2025 and January 2026 showed that on multiple weekend days, the number of licensed nurses and CNAs scheduled fell below these minimums. On specific dates, day and night shifts were staffed with fewer licensed nurses than required, and several day and night shifts were staffed with fewer CNAs than the assessment’s minimums. Payroll Based Journal data further showed the facility triggered for low weekend staffing for all four quarters of federal fiscal year 2025, establishing a history of low weekend staffing. In addition to low numbers, staffing patterns showed that licensed nurses and CNAs frequently picked up resident assignments in cottages that did not have regularly assigned staff. Staff interviews confirmed that some cottages, such as Aniak, did not have a regular nurse assigned and instead relied on float nurses from other cottages. A CNA reported feeling unable to provide good quality care because of rushing and expressed concern about resident falls due to having only one nurse and one CNA in the cottage. Another nurse stated there was only one CNA caring for residents and that if that CNA called in sick, CNAs from other cottages would pick up assignments. An anonymous resident reported that staff shortages were a big problem, with shared nurses and CNAs, and described long waits and receiving bed baths instead of showers when CNAs did not have time. The insufficient staffing directly affected the provision of ADLs for specific residents. One resident with quadriplegia, dependent on staff for showers and whose care plan required showers every Sunday and Thursday night using a Carendo chair, did not receive showers as scheduled. Shower logs showed a 14-day gap between showers in December 2025, with bed baths documented instead on some scheduled shower days and no documentation of shower or bed bath on another scheduled day in January 2026. This resident stated they had not been showered for three weeks in December and again on a recent scheduled day because staff told them there were not enough CNAs, and also reported long waits for call light responses and staff declining to assist with small tasks due to being too busy. Another resident with multiple sclerosis, muscle weakness, and functional quadriplegia, who was dependent on staff for transfers and required one-person assistance with an overhead lift, experienced reduced opportunities to get out of bed. Social service documentation noted the resident’s interest in being transferred to a chair more than once a week and identified staffing concerns as a primary factor because the transfer was a two-person assist, leading to decreased participation in usual activities when left in bed. The resident later filed a grievance stating they were concerned about only being able to get out of bed once per week and had been told this limitation was due to staffing, requesting to get up three times per week. CNA task logs showed that over several weeks in December 2025 and early January 2026, the resident was not consistently gotten up on the scheduled days, including an entire week with no documented transfers out of bed. The resident reported that when they asked to get up, staff often responded that they would see, which usually meant no, citing being shorthanded or too many people getting up at once.
Failure to Notify Guardian of Behavioral Health Consultation
Penalty
Summary
The facility failed to ensure a court-appointed guardian was informed of and able to participate in care decisions for a resident with multiple complex medical and mental health diagnoses, including multiple sclerosis, renal tubule-interstitial disease, bipolar disorder, delusional disorder, and anxiety disorder. The resident had a LETTER OF GUARDIANSHIP dated 4/17/14 that appointed the Office of Public Advocacy as full guardian, with explicit authority over medical care, mental health treatment, physical and mental examinations, and approval of all medications, medical procedures, and psychotropic medications. Despite this, the resident was sent to a behavioral health consultation on 10/22/25, during which the consultation report documented that the patient was unescorted, that documentation at the time of the visit indicated a guardian/POA, and that the patient was unable to explain the reason for the visit. The consultant recommended obtaining more information about the reason for the visit and guardian contact. Interviews and document reviews showed there was no documented guardian notification regarding the scheduled psychiatric consultation. The Administrator and DON confirmed there was no documented guardian notification. The staffing schedule for the date of the appointment noted the resident needed an escort, but the DON could not verify who the escort was. An email from the Assistant Administrator stated that the facility’s driver provided transportation and ensured check-in, and referenced a recent BIMS indicating intact cognition, which the facility typically used to determine that an escort was not required. The same email and a follow-up email acknowledged that it was standard practice to notify residents and representatives of appointments, but there was no documentation in the chart confirming guardian notification for this mental health appointment. The guardian later stated it was possible they had been made aware but could not recall due to a large caseload, and there was no facility documentation verifying that notification or consent had occurred.
Failure to Provide ADL Care per Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) services in accordance with assessed needs, care plans, and resident preferences for two residents. One resident with quadriplegia was care planned to receive showers every Sunday and Thursday night using a Carendo chair and was documented on the MDS as being fully dependent on staff for bathing. The resident’s MDS also reflected a preference for showers. Progress notes reiterated the order for showers every Sunday and Thursday night with licensed nurse skin evaluations. Despite this, the December shower log showed the resident did not receive a shower between 12/18 and 12/28 and instead received bed baths on two of those days, and the January log showed missed scheduled showers on 1/1 and 1/5, with only a bed bath documented on 1/1 and no shower or bed bath documented on 1/5. During interview, this resident stated they were dependent on staff for ADLs such as showering and reported not receiving a shower for three weeks in December and again on the prior day because staff told them there were not enough CNAs available. The resident also reported long waits for call light responses, sometimes 30–40 minutes, and stated that staff told them they were too busy when the resident requested assistance with smaller tasks such as getting water or adjusting the TV volume, even when staff were already in the room. The Director of Nursing reported that showers were audited twice a week and discussed during rounds and that CNAs were supposed to notify a nurse or supervisor if a resident did not receive a shower. The second resident had multiple sclerosis, muscle weakness, and functional quadriplegia and was documented on the MDS as having upper and lower limb impairments and being dependent on staff for bed-to-chair transfers. The care plan required supervision and physical assistance with transfers using a one-person overhead lift. A social service note documented that the resident wanted to be transferred to a chair more than once a week, identified staffing as a barrier due to being a two-person transfer, and reported decreased participation in usual activities when left in bed. A grievance later documented the resident’s concern about only being able to get out of bed once per week and their request to get up on Monday, Wednesday, and Friday. CNA task documentation directed staff to ensure the resident was up every Monday, Wednesday, and Friday, but the task log showed that over several weeks in December and early January the resident was either not gotten up at all or only once per week on specified dates. In interview, the resident stated they did not get out of bed twice during December and that when they asked to get up, staff often responded that they would see, which usually meant no due to being short-handed or too many people getting up at once, despite the plan of care specifying three times per week.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure that residents were discharged in a manner that protected their health, safety, and psychosocial well-being. Specifically, the facility did not develop or implement an effective discharge planning process for two residents, resulting in unsafe and inappropriate discharges. The facility lacked documented standards for discharge planning, relying instead on verbal expectations within the social services department. Discharge planning was limited to care conferences at admission and two weeks prior to discharge, with no ongoing reassessment or structured involvement of resident representatives. The facility also did not conduct home visits prior to discharge, and referrals for post-discharge services and equipment were inconsistently arranged or delayed. One resident was discharged to a home environment that was known to be unsafe and inaccessible, without adequate caregiver support or required services in place. The resident, who had a history of joint replacement surgery, infection, and a recent femur fracture, required wound care, mobility assistance, and ongoing medical follow-up. Despite the resident's home being multi-level, in disrepair, and infested with rodents, the facility proceeded with discharge planning that did not ensure safe access or adequate support. The resident was left reliant on unplanned third parties, such as the fire department and community members, for essential care and experienced distress, emotional harm, and physical compromise, including a fall after discharge. Another resident with cognitive impairment, acute behavioral changes, and a documented need for nursing facility level care and specialized mental health services was discharged without required referrals or representative involvement. The facility did not review or incorporate the resident's PASRR Level II findings into the discharge plan, nor did it address a documented change in condition on the day of discharge. As a result, the resident experienced distress, confusion, and loss of security, with the POA having to assume unplanned caregiving responsibilities to prevent harm. The failures in discharge planning led to actual physical and psychosocial harm for both residents.
Failure to Incorporate PASRR Level II Findings into Care and Discharge Planning
Penalty
Summary
The facility failed to comply with PASRR (Pre-admission Screening and Resident Review) requirements by not incorporating the PASRR Level II determination into the assessment, care planning, and discharge planning for a resident with multiple mental health diagnoses. The PASRR Level II evaluation, which identified the need for continued nursing facility services and specialized mental health services, was not available at the time of admission and was not reviewed during the resident's stay or at discharge. The Level II report was only retrieved after the resident had already been discharged, and its recommendations were not integrated into the resident's care plan or discharge process. The resident in question had a complex medical history, including dementia, depression, anxiety, delirium, encephalopathy, and a recent femur fracture with surgical site infection. The PASRR Level II assessment specifically noted the need for specialized services to address mental health needs and provided recommendations for care and discharge options. Despite these findings, the facility did not order or initiate any specialized mental health services during the resident's stay. The care plan was delayed and, when eventually updated, did not include the specialized services recommended by the PASRR Level II evaluation. Throughout the resident's admission, there were documented episodes of aggression, combativeness, and non-compliance, which led to the initiation and escalation of psychotropic medications. The discharge summary and post-care instructions did not address the need for specialized mental health services or follow the recommended discharge options outlined in the PASRR Level II report. Facility staff acknowledged that the lack of access to and review of the PASRR Level II report negatively impacted the adequacy of care planning and discharge for the resident.
Failure to Provide Appropriate Pressure Ulcer Care and Timely Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a facility-acquired pressure ulcer. The resident, who had significant comorbidities including end-stage renal disease and diabetes, developed multiple wounds during their stay, including a left iliac crest pressure injury and sacral wounds. There were significant delays and inconsistencies in wound assessment and treatment orders, with documented discrepancies between wound care provider recommendations and the actual orders transcribed and implemented by nursing staff. For example, wound care interventions recommended by the wound care team were not consistently reflected in the Treatment Administration Record (TAR), and antibiotics were not always administered as prescribed, particularly in relation to the resident's dialysis schedule, resulting in subtherapeutic dosing. Documentation revealed that wound care interventions were not promptly added to the resident's care plan, with a delay of 21 days after wounds were first identified. There was also a lack of documentation regarding the resident's reported noncompliance with repositioning and wound care, as noted by the wound care provider, with no corresponding nursing or CNA notes, risk/benefit documentation, or care plan updates to address these issues. Additionally, there was a failure to initiate and document referrals for higher-level wound care as recommended by external providers, and the facility did not coordinate or document efforts to ensure the resident attended outpatient wound care or follow-up appointments, despite family requests and external provider recommendations. Throughout the resident's stay, wound healing was minimal, and infections persisted despite multiple rounds of antibiotics, which were at times administered incorrectly or not as ordered. The lack of timely and appropriate wound care interventions, poor communication and documentation among staff, and failure to coordinate necessary higher-level care contributed to the resident's hospitalization with sepsis and subsequent death. The facility's actions and inactions directly resulted in a deficiency related to the provision of pressure ulcer care and prevention of new ulcers.
Systemic QAPI Failures Result in Multiple Deficiencies Across Facility Operations
Penalty
Summary
The facility failed to develop, implement, and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, analyzed, and corrected systemic quality deficiencies. Despite collecting data from various sources such as electronic health records, staffing reports, maintenance logs, and resident council feedback, the QAPI committee did not effectively use this information to identify trends, prioritize high-risk issues, or implement and sustain corrective actions. This resulted in ongoing patterns of deficient practice in areas including staffing, grievance process, clinical care, activities, medication management, therapy services, discharge planning, environmental conditions, and care planning. Internal reports, resident council concerns, medical record documentation, staffing data, and direct observation all indicated these issues, but they were not recognized or acted upon through the QAPI process. Staffing deficiencies were evident, particularly on weekends, where staffing levels consistently fell below the facility's own assessment standards. Payroll Based Journal (PBJ) data and review of staffing schedules showed that the number of nurses, CNAs, and restorative aides scheduled was frequently less than the minimum required. Residents reported long wait times for assistance, with one resident waiting over two hours to be helped out of bed, and another experiencing delays in having a urinal emptied. Resident council meeting minutes repeatedly documented concerns about inadequate staffing and slow response times, with little evidence of effective facility response or improvement. The administrator and QAPI committee were not aware of the low weekend staffing, relying instead on reports that did not reflect actual staffing shortages. Additional deficiencies included failures in the grievance process, where residents were not properly informed of the current grievance officer, and posted information was outdated. Residents and council members were unaware of the new grievance officer, and there was no documentation of her introduction or updated contact information. The activities program was also deficient, with multiple residents reporting that they were not offered or able to participate in activities as documented in their care plans and assessments. Activity flowsheets showed minimal or no activity participation or offers for extended periods. Medication management was compromised by incomplete narcotic count documentation, with missing required signatures in narcotic logbooks across multiple units and months. Physical therapy services were not provided as ordered for a resident due to staff absence, with no evidence of alternative arrangements or continuity of care.
Failure to Follow Physician Orders and Care Plans for Vital Signs and Pressure Reduction
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and person-centered care plans for two residents. For one resident with a history of hypertension, heart failure, and transient ischemic attack, there was a physician's order for daily vital signs and an order for antihypertensive medication. However, record review showed that vital signs were only documented twice over a period of 177 days, despite the daily order. The acting DON confirmed that daily monitoring should have occurred, and facility policy required vital signs to be monitored as ordered for residents on antihypertensive medications. For another resident with diagnoses including weakness, mild cognitive impairment, and osteoarthritis, there were orders for wound care to leave the left heel open to air and to use offloading boots for the left lower extremity. Observation revealed the resident was lying in bed with both heels on the mattress and covered by non-skid socks, with no offloading boots in place. The care plan did not include interventions for keeping the left heel open to air or for the use of offloading boots, and a licensed nurse confirmed the order for heel boots. Facility policy required care plans to reflect services necessary to maintain the resident's highest practicable well-being and to follow recognized standards of practice.
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