Heritage Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Soldotna, Alaska.
- Location
- 232 Rockwell Avenue, Soldotna, Alaska 99669
- CMS Provider Number
- 025021
- Inspections on file
- 19
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Heritage Place during CMS and state inspections, most recent first.
Surveyors found that the DON, who also served as Administrator, worked only 35 hours per week in the DON role and 5 hours as Administrator, rather than the required 40 hours per week as DON. The DON did not use a timecard system and allocated her hours based on her own schedule, as confirmed by interviews and review of the position description.
Surveyors observed expired urethral catheters and suction catheters without expiration dates in the central supply room. The Support Services Manager admitted there was no effective process for verifying expiration dates on supplies lacking visible labels, and staff relied on weekly checks and spot inspections that failed to prevent expired or unlabeled items from remaining in stock.
Surveyors found that food items, including spices and bread, were not properly labeled with open dates or stored according to facility policy in both the main kitchen and a unit kitchenette. Multiple opened containers lacked required labeling, and some packaging was torn, exposing food. The Food Service Supervisor confirmed that labeling procedures were not consistently followed.
Three residents on pureed diets, all with conditions such as dysphagia and dementia, were served foods that did not meet the required IDDSI Level 4 consistency. Staff prepared pureed foods to a runny, pourable texture without using standardized tests or tools, and some recipes were missing. Observations confirmed that the foods did not hold their shape or pass the facility's own consistency tests, contrary to policy and dietary guidelines.
The facility did not update care plans to reflect changes in three residents' needs, including the use of a foot cradle for a resident with hammertoes and an arterial ulcer, increased assistance with ADLs and oral hygiene for a resident with cognitive and functional decline, and the implementation of enhanced barrier precautions for a resident with an infection. Staff confirmed these omissions, and facility policy requires care plans to be revised as residents' conditions change.
A resident with dementia and heart conditions, who had become dependent on staff for daily care, did not consistently receive oral hygiene as ordered. Documentation showed oral care was provided less frequently than required, and neither the Kardex nor the care plan included updated instructions for oral hygiene. The DON confirmed that the care plan should have reflected the resident's current needs.
A resident with multiple diagnoses had several telephone/verbal medication orders where physician signatures were present but lacked dates and times. The RCC entered these orders into the EMR, but there were no individual electronic physician signatures or time/date stamps. The DON confirmed that signatures should be dated and timed, but the current process did not ensure this, resulting in incomplete medical records.
CNAs did not change gloves or perform hand hygiene between contaminated and clean tasks while providing personal care to two residents. Staff wore the same soiled gloves during multiple care activities, including perineal care, dressing, repositioning, and handling personal items, only removing gloves and sanitizing hands after all tasks were completed. Facility leadership confirmed this practice did not align with policy or CDC guidelines.
The facility failed to meet food safety standards, with improper food storage and labeling in the main kitchen and Sitka unit, and inadequate dishwasher temperatures for sanitation. Observations revealed unlabeled and expired food items, and staff were not consistently following safety protocols, such as wearing hairnets. The dishwasher frequently operated below the required temperature, compromising dish sanitation.
A facility failed to use a properly sized sling for a resident during transfers, causing discomfort and anxiety. Additionally, the facility did not perform necessary neuro checks after unwitnessed falls for two residents, one with cerebral infarction and aphasia, and another with dementia. The facility's policies lacked clear guidance on neuro assessments for unwitnessed falls, leading to inconsistencies in care and potential risks to resident safety.
A resident with dementia and a history of wandering successfully eloped from a facility due to the use of an outdated wander guard battery tester. The device failed to accurately assess the battery status, resulting in the wander guard not functioning properly. Despite regular checks, the resident's wander guard did not trigger the door alarm during the elopement.
Expired medical supplies, including catheters and syringes, were found in the facility's central supply room and Sitka Unit. Nurses and the Support Services Manager were responsible for checking expiration dates, but expired items remained, indicating a lapse in supply management.
The facility failed to ensure that RAs, LNs, and Food Service Staff were properly trained and certified to prepare modified diets using a Cuisinart food processor. Observations revealed improper food preparation practices, such as not wearing hairnets and manually removing unprocessed food pieces. Interviews indicated a lack of formal training and awareness among staff, and a review of resident diet orders showed discrepancies. Additionally, RAs and LNs lacked the required food worker cards, violating state regulations.
DON Did Not Meet Full-Time Hour Requirement
Penalty
Summary
The facility failed to ensure that the designated Director of Nursing (DON) worked the required 40 hours per week as stipulated by regulation. Interviews with the DON revealed that she was also serving as the facility Administrator and divided her workweek into 35 hours for DON duties and 5 hours for Administrator duties. The DON confirmed that she did not complete a timecard and was not required to clock in, instead allocating her time based on her own schedule. A review of the position description indicated that the role required a minimum of 35 hours per week for DON responsibilities, but the regulation cited (F354) requires a full-time DON, which is generally interpreted as 40 hours per week. Handwritten notes attached to the position description confirmed the division of hours between DON and Administrator roles. This practice resulted in the DON not fulfilling the full-time requirement for the DON position, as observed and documented by surveyors.
Expired and Unlabeled Medical Supplies Found in Central Supply Room
Penalty
Summary
The facility failed to ensure that medical supplies in the central medical supply room were properly labeled and removed from storage if expired. During an observation, surveyors found expired Bard urethral catheters and several sterile suction catheters without documented expiration dates. The Support Services Manager (SSM) acknowledged that some supplies were sourced from the hospital and admitted there was no established process for verifying expiration dates on items lacking visible dates. The SSM also stated that expiration dates were checked weekly, but there was not a good process in place to verify expiration dates, especially for supplies without clear labeling. Additionally, a licensed nurse indicated that expired items were expected to be disposed of by nursing staff, and products without expiration dates would be reported to the nurse manager. Review of the facility's policy revealed that department managers were responsible for monitoring supply dates, with the SSM conducting spot inspections during bi-weekly housekeeping checks. However, the presence of expired and unlabeled supplies indicated that these procedures were not effectively implemented, resulting in the deficiency.
Failure to Properly Label and Store Food Items
Penalty
Summary
The facility failed to ensure that food was stored under proper sanitary conditions in both the main kitchen and the Sitka unit, as observed during a survey. In the main kitchen, multiple opened containers of spices and other dry goods were found without open dates, despite being received as far back as 2019. Additionally, items in the resident/family refrigerator, such as an opened bottle of syrup and a half loaf of bread, were not labeled with open dates. The Food Service Supervisor confirmed that all containers should be labeled with both received and open dates, and that staff typically notify her when items appear close to empty, rather than following a systematic labeling process. In the Sitka unit's kitchenette, a half loaf of cinnamon raisin bread was found with torn packaging, exposing the bread, and had been opened several days prior. Review of facility policies revealed clear requirements for labeling and dating all food items, monitoring supply dates, and following USDA recommendations for food storage and shelf life. However, these policies were not followed, as evidenced by the lack of labeling and improper storage practices observed during the survey.
Failure to Prepare Pureed Foods to Required Consistency
Penalty
Summary
The facility failed to ensure that pureed foods were prepared to the appropriate consistency for three residents who required pureed/level four texture diets due to conditions such as multiple sclerosis, Alzheimer's disease, dementia, depression, and dysphagia. Record reviews confirmed that these residents were prescribed pureed diets, and observations in the kitchen revealed that staff blended foods, such as ham and tomato soup, to a runny, pourable consistency rather than the required pudding-like texture. The staff member responsible for preparing these foods did not use any standardized tests or tools to verify the correct consistency, instead relying on visual estimation. Additionally, there was no recipe available for pureed tomato soup, and the recipe for pureed ham specified a pudding-like consistency that was not achieved. Further observations showed that pureed corn served for dinner did not hold its shape on a spoon and dripped continuously through fork prongs, failing to meet the facility's own IDDSI guidelines for pureed foods. The facility's policy and IDDSI handouts specified that pureed foods must hold their shape on a spoon, fall off in a single spoonful, and not separate into liquids and solids, with specific tests to confirm the correct texture. Despite these guidelines and policies, the pureed foods prepared and served did not meet the required standards for residents on pureed diets.
Failure to Revise Care Plans for Changing Resident Needs
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to address the changing needs of three residents. For one resident with vascular dementia and bone disorders, a foot cradle was observed in use for several weeks to protect the toes from blanket contact due to hammertoes and an arterial ulcer, but this intervention was not included in the resident's care plan. Staff interviews confirmed the use of the foot cradle and acknowledged it should have been care planned, but it was omitted. Another resident with dementia, congestive heart failure, and ischemic cardiomyopathy experienced a decline in cognition and ability to perform activities of daily living (ADLs), including increased dependence on staff for oral hygiene, feeding, and dressing. Despite these changes, the care plan had not been updated since the previous year and continued to state the resident was independent in most ADLs. The MDS nurse and DON confirmed awareness of the resident's decline and that the care plan did not reflect the current needs for assistance with ADLs and oral hygiene. A third resident with cellulitis, peripheral vascular disease, and under palliative care was placed on enhanced barrier precautions (EBP) due to infection, as indicated by signage and staff interviews. However, the use of EBP was not documented in the resident's care plan, despite being active in the electronic medical record. The ADON confirmed that EBP should have been included in the care plan. The facility's policy requires care plans to be revised as residents' conditions change, but this was not done for these residents.
Failure to Provide Consistent Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with dementia, congestive heart failure, and ischemic cardiomyopathy did not consistently receive oral care as required. The resident had recently experienced a decline in health, affecting cognition and dexterity, which increased reliance on staff for activities of daily living, including oral hygiene. During an interview and observation, the resident's representative expressed concern about the lack of regular oral care, and notable bad breath was observed. Record review showed that oral hygiene was ordered to be performed every shift (twice daily), but documentation revealed that the resident only received oral care once daily on ten occasions out of 56 opportunities. Additionally, the resident's Kardex did not include instructions for oral hygiene assistance, and the care plan lacked interventions addressing oral hygiene needs. The DON confirmed that oral care should be performed at least once per 12-hour shift and acknowledged the care plan should have been updated to reflect the resident's current needs.
Incomplete Physician Signatures on Verbal Orders
Penalty
Summary
The facility failed to ensure that medical records were complete for one resident, as physician signatures on written telephone/verbal orders were not dated or timed. Record review showed multiple telephone/verbal order slips for a resident with complex medical needs, including cellulitis, peripheral vascular disease, and palliative care, where the physician's signature was present but lacked an associated date and time. These orders included medication changes and new prescriptions, all of which were entered into the electronic medical record (EMR) by the Resident Care Coordinator (RCC), but without individual electronic physician signatures or designated time and date stamps. Interviews with the RCC and the Director of Nursing (DON) confirmed that the process involved physicians signing order slips during weekly visits, but the signatures were not consistently dated or timed. The DON acknowledged that all physician signatures on verbal orders should include a date and time, and clarified that physicians did not enter orders or progress notes directly into the facility's EMR, but rather into a separate hospital-associated EMR. This practice resulted in incomplete medical records for the resident.
Failure to Follow Infection Control Procedures During Personal Care
Penalty
Summary
Certified Nurse Assistants (CNAs) failed to follow proper infection control procedures while providing personal care to two residents. During observations, CNAs did not change gloves or perform hand hygiene between tasks, such as after perineal care and before touching clean body sites or handling personal items. For one resident, CNAs wore the same soiled gloves while assisting with dressing, applying creams, repositioning, and handling a Hoyer lift sling, only removing gloves and sanitizing hands after multiple tasks were completed. In another instance, a CNA wore the same soiled gloves while assisting with perineal care, dressing, repositioning, and handling personal items, only removing gloves and wiping hands with a sanitizing wipe after all tasks were finished. Interviews with facility leadership confirmed that the expectation, according to facility policy and CDC guidelines, is for staff to perform hand hygiene and change gloves after contact with contaminated body sites and before moving to clean tasks or handling resident belongings. Review of facility policy and CDC guidelines further supported the need for hand hygiene before moving from a contaminated to a clean body site, after contact with blood or bodily fluids, and immediately after glove removal. The observed failures to follow these procedures constituted a deficiency in the facility's infection prevention and control program.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, resulting in multiple deficiencies in food storage, preparation, and sanitation. During an inspection of the main kitchen, it was observed that several food items were improperly stored without open dates, including various noodles, sauces, and condiments. Additionally, a pan of cooked food was left uncovered on a prep table, exposing it to potential contamination. The Dietary Manager confirmed that all containers should be labeled with an open date, and that kitchen staff are required to wear hairnets, which was not adhered to by a Food Service Assistant during food preparation. On the Sitka [NAME] unit, further deficiencies were noted in the kitchenette area. Observations revealed expired and improperly labeled food items, such as Pedialyte electrolyte powder and microwave popcorn, as well as various condiments without open dates. The facility's policy mandates that all food items be dated before storage and that expired items be removed from inventory, which was not followed in this instance. The facility also failed to maintain proper dishwasher temperatures necessary for effective sanitation. The dishwasher's temperature logs showed frequent instances where the wash, rinse, and sanitization cycles were below the required 120 degrees Fahrenheit. Interviews with staff revealed a lack of awareness regarding the target temperature range, and observations showed that the dishwasher often required multiple cycles to reach adequate temperatures. The Support Services Manager acknowledged the need for the dishwasher to reach 130 degrees Fahrenheit for proper sanitation, which was not consistently achieved.
Improper Sling Use and Lack of Neuro Checks in LTC Facility
Penalty
Summary
The facility failed to ensure the use of a properly sized sling during transfers for a resident, which resulted in discomfort and anxiety for the resident. The resident, who had a history of lung cancer, COPD, peripheral vascular disease, and atrial fibrillation, expressed fear and discomfort when using the lift due to the inappropriate sling size. The staff used a large sling instead of a medium one, which was not suitable for the resident's weight of 143.6 lbs. This improper sizing led to the resident experiencing pain during transfers, as the sling bunched up under the arms and exposed the midsection. Additionally, the facility did not perform neurological checks after unwitnessed falls for two residents. One resident, with a history of cerebral infarction and aphasia, experienced multiple unwitnessed falls, yet no neuro checks were documented. The resident was unable to communicate effectively, making it crucial to perform thorough assessments after falls. Similarly, another resident with dementia had an unwitnessed fall, but no neuro checks were conducted, despite the presence of a contusion and abrasion. The facility's policies and procedures lacked clear guidance on conducting neuro checks for unwitnessed falls. Interviews with staff revealed inconsistencies in understanding and implementing fall protocols, particularly regarding neuro assessments. The absence of documented neuro checks and the improper use of lift slings indicate a failure to adhere to established care standards, potentially compromising resident safety and well-being.
Outdated Wander Guard Testing Device Leads to Resident Elopement
Penalty
Summary
The facility failed to adequately monitor the functional status of wander guard tags, which are safety devices used to prevent elopement in residents at risk of wandering. Specifically, the facility used an outdated and obsolete tag battery tester that was incapable of accurately indicating the battery level status. This deficiency was identified in the case of a resident with dementia who had a history of wandering. The resident's care plan included the use of a wander guard on their ankle, with instructions for staff to ensure the device was in place every shift and for the Resident Aide supervisor to check its function weekly. Despite these measures, the resident experienced two successful elopements and two additional elopement attempts. During one successful elopement, the resident was found in the parking lot, and it was discovered that the wander guard battery was not working, preventing the door alarm from activating. The facility's testing log indicated that the resident's tag had been tested the day before and was deemed functional. However, interviews with staff and an Accutech representative revealed that the testing device used was outdated and unable to provide an accurate assessment of the battery's status, leading to the failure of the wander guard system.
Expired Medical Supplies Found in Facility
Penalty
Summary
The facility failed to ensure that expired medical products were removed from the medical supply storage areas, which placed all residents at risk for adverse effects or complications from using these expired products. During an observation and interview in the Central Medical Supply Room, several expired medical supplies were found, including Bard Urethral Catheterization trays and urethral catheters with coude tips. Licensed Nurse #1 indicated that the maintenance department was responsible for stocking the central supply room, while nurses checked expiration dates as they gathered supplies to stock the nurses' stations. However, expired items were still present, indicating a lapse in this process. In the Sitka Unit Medication/Supply Corner, additional expired medical supplies were discovered, including a BD 5 ml syringe and a Bard Urethral Catheterization tray. Licensed Nurse #3 stated that staff checked expiration dates when stocking supplies, which were gathered from the central medical supply room. The Support Services Manager, responsible for ordering and stocking the central supply room, acknowledged that expired products might have been received. The facility's policy required department managers to monitor supplies, with the Support Services Manager conducting spot inspections during bi-weekly housekeeping inspections. Despite these procedures, expired items were not removed from inventory, highlighting a deficiency in the facility's supply management practices.
Deficiency in Training and Certification for Modified Diet Preparation
Penalty
Summary
The facility failed to ensure that Resident Aides (RAs), Licensed Nurses (LNs), and Food Service Staff were properly trained and certified to prepare modified diets for residents on the Sitka unit. Specifically, the staff were not trained to operate a Cuisinart chopper/grinder food processor used for preparing these diets, and RAs and LNs did not possess food worker cards to certify their training in food preparation. This deficiency was identified through observations and interviews, revealing that staff were preparing modified diets without the necessary training and certifications, which placed residents at risk for improper food preparation and potential foodborne illnesses. During observations, it was noted that an RA prepared a minced and moist modified diet for a resident using the Cuisinart food processor without wearing a hairnet, and manually removed larger pieces of sausage that were not properly processed. Interviews with the Dietary Manager and Dietician indicated a lack of awareness and training regarding the use of the food processor on the unit. The Dietician was unaware of the food processor's use on the unit, and the Dietary Manager provided incorrect information about the processor's capabilities for preparing specific diet levels. Further interviews revealed that RAs and LNs were teaching each other how to use the food processor, rather than receiving formal training. Additionally, a review of resident diet orders showed discrepancies between the prescribed diets and the diets being prepared. The facility's policy on food safety and the requirement for food worker cards were not being followed, as confirmed by the Administrator, who stated that no RAs or LNs had food worker cards, despite state requirements for such certification.
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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