Ketchikan Med Ctr New Horizons Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Ketchikan, Alaska.
- Location
- 3100 Tongass Avenue, Ketchikan, Alaska 99901
- CMS Provider Number
- 025010
- Inspections on file
- 18
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Ketchikan Med Ctr New Horizons Transitional Care during CMS and state inspections, most recent first.
Residents were denied the right to have invited guests, including family members and local officials, attend a resident council meeting to discuss concerns about activities and staffing. Despite residents expressing their wishes for these visitors to stay, the Administrator required all non-residents to leave before the meeting could proceed, contrary to facility policies that support resident rights to visitation and group participation.
Multiple residents and staff reported that the Administrator engaged in verbally abusive behavior, including negative comments, a loud and mean tone, and dismissive interactions. These actions caused residents to feel unsafe, anxious, and emotionally distressed, with staff and the CNO corroborating the concerns and observing inappropriate conduct during a resident council meeting. Facility documentation and policies confirmed the definition of verbal abuse and residents' rights to be free from such treatment.
The facility did not follow its abuse investigation policies after a resident alleged verbal abuse by the Administrator. The CNO failed to document key interviews, did not notify the resident's provider, and did not investigate when two other residents reported similar concerns. Risk Management and HR did not adequately monitor or document the investigation, and the facility lacked a functioning grievance committee, resulting in incomplete handling of the abuse allegation.
The facility did not submit the required results of an abuse investigation to the State Agency within the mandated timeframe. The CNO was unable to provide proof that the final report was sent, and only an initial report was available, lacking investigation results. This failure prevented the State Agency from properly assessing the abuse allegation.
Float and travel nursing staff assigned to the LTC unit did not have current training in essential areas such as ADL coding, behavioral health, QAPI, dementia care, and trauma-informed care. Interviews confirmed that only abuse and neglect training was required and tracked for these staff, and several staff reported receiving only general orientation without LTC-specific education. This deficiency affected all residents, many of whom required assistance with ADLs and had behavioral health conditions.
The facility did not review and update its facility-wide assessment on an annual basis, as required. The most recent assessment update was not current, and the CNO acknowledged the need for an update. This deficiency had the potential to impact all residents in the facility.
Four float CNAs worked in the LTC unit without completing the required 12 hours of annual in-service training, including education on dementia care and abuse/neglect prevention. Facility records and staff interviews confirmed that these CNAs did not receive LTC-specific training, and only completed an online module focused on abuse and neglect, which did not include dementia care. This failure placed all residents at risk for substandard care due to insufficient staff education.
A resident reported feeling verbally abused by the Administrator, but the facility failed to accurately interview the resident, did not document key interviews, and did not contact the resident's provider as required. During the investigation, two other residents reported feeling verbally abused by the Administrator, but their concerns were not investigated. These actions resulted in an incomplete investigation and failure to address all reported concerns.
A deficiency was identified when the facility did not consistently provide scheduled activities or outings as documented on the activity calendar, and failed to honor residents' individual care plan preferences. Multiple residents, including those with dementia, were excluded from outings and group activities due to administrative decisions and staffing shortages. Residents and staff reported frequent cancellations of activities, closure of the activity department, and restrictions on the use of the facility van and cooking groups, resulting in residents feeling isolated and dissatisfied.
An Administrator took a resident's checkbook against the resident's wishes, citing concerns from the POA and Medicaid application needs, and stored it in a personal desk instead of the facility safe. The resident expressed anger and distress, and staff observed the Administrator's coercive and dismissive behavior. There was no documentation of the incident in the medical record, and the actions were not consistent with facility policy or standard practice.
A resident with Type 1 Diabetes Mellitus experienced significant blood glucose fluctuations after their insulin pump was discontinued upon admission to a facility. The resident's blood glucose levels ranged from 52 to 468 mg/dL, leading to symptoms such as fatigue, headaches, and an inability to participate in daily activities. The facility's inconsistent management of the resident's diabetes compromised their physical and mental well-being.
A resident with Type 1 Diabetes Mellitus experienced significant blood glucose fluctuations after their insulin pump was discontinued upon admission to the facility. The facility failed to manage these fluctuations effectively, resulting in episodes of hypoglycemia and hyperglycemia. The resident's physical and psychosocial well-being was compromised, as they experienced fatigue, headaches, and an inability to participate in therapy sessions. Interviews with the resident, their spouse, and staff highlighted concerns about the resident's unstable blood glucose levels and the lack of effective management.
The facility failed to update care plans for two residents, one on anticoagulant medication and another with chronic shoulder pain. A resident's care plan did not reflect ongoing use of Apixaban, a high-risk anticoagulant, after it was removed, despite continued use. Another resident's chronic right shoulder pain was not included in their care plan, despite ongoing complaints and documentation in progress notes. These omissions indicate a lapse in the facility's care planning process.
The facility failed to provide a meaningful activities program for a resident with multiple diagnoses, including Alzheimer's dementia and schizoaffective disorder. The resident's preferences were not discussed or documented, and an activities program was not developed until the last day of the survey.
A resident with primary osteoarthritis and bilateral leg weakness did not receive the full scope of ordered restorative exercises, as only ankle pumps were provided and hip reductions were omitted. The facility lacked a policy on restorative exercises, and documentation issues contributed to the oversight.
The facility failed to post the total number and actual hours worked by CNAs, LPNs, and RNs per shift. The Unit Clerk was unaware of the requirement to post actual and total hours per shift, and a review of the Daily Staffing Sheet confirmed the deficiency.
Residents' Rights to Invite Guests to Council Meetings Not Honored
Penalty
Summary
The facility failed to honor residents' rights to organize and participate in resident or family groups by not allowing resident-invited visitors and guests to attend a resident council meeting. Multiple residents, including the president of the resident council, expressed that they had invited family members and local officials, such as the Mayor and City Council members, to attend a meeting to discuss concerns about limited activities and low staffing. Despite these invitations, the facility Administrator required the visitors to leave, stating that the meeting was for residents only and that visitors could not attend unless previously approved by a vote at an earlier meeting. Residents and their representatives reported that they wanted the visitors present to support them and to hear their concerns. Several residents voiced their wishes directly to the Administrator during the meeting, but the Administrator insisted that the visitors vacate the room before the meeting could proceed. The Chief Nursing Officer confirmed that residents had requested the visitors to stay, but the Administrator did not allow it. One visitor stated that the Administrator expressed concerns about the meeting becoming political and repeatedly asked the visitor not to attend, leading the visitor to leave to avoid causing disruption. A review of the facility's policies revealed that residents have the right to invite visitors of their choosing and to organize and participate in resident and family groups. However, the Resident Council Meetings Policy did not specify that residents were permitted to invite visitors to the meetings, and there was no documentation supporting this right in practice. The actions taken by the Administrator directly contradicted both resident wishes and facility policy statements regarding resident rights and visitation.
Administrator's Verbal Abuse Toward Residents
Penalty
Summary
The facility failed to ensure residents were free from abuse, specifically verbal abuse, as evidenced by multiple interviews and observations involving the Administrator's conduct. Residents reported feeling verbally abused and intimidated by the Administrator's negative comments, loud and mean tone, and dismissive behavior. One resident described feeling very sad, hopeless, and physically shaken when recounting their experience, while another stated they felt scared and unsafe due to the Administrator's manner of speaking. Staff corroborated these concerns, noting that residents had reported not feeling safe and that the Administrator's interactions were rough and lacked respect. The Chief Nursing Officer (CNO) acknowledged receiving feedback about the Administrator's behavior and personally witnessed the Administrator addressing residents in a raised voice with animated gestures during a resident council meeting, which made the CNO and the group feel anxious and uncomfortable. Additional staff confirmed the Administrator's rude tone and tendency to cut off residents in conversation. Review of the facility's abuse investigation documentation revealed that another resident also felt verbally abused by the Administrator. The facility's own policies define verbal abuse as the use of oral, written, or gestured language that includes disparaging or derogatory terms, and guarantee residents' rights to dignity, respect, and freedom from abuse.
Failure to Implement and Document Abuse Investigation Procedures
Penalty
Summary
The facility failed to implement and follow its written policies and procedures for investigating an allegation of abuse involving one resident. After a resident stated during a council meeting that they felt verbally abused by the Administrator, the Chief Nursing Officer (CNO) initiated a state report and began an investigation. However, the CNO did not document the interview with the resident, did not interview or document an interview with the Administrator, and did not notify the resident's provider of the allegation. The CNO also had a nurse interview five other residents, but the documentation of these interviews was undated, and the CNO did not investigate further when two of these residents reported feeling verbally abused by the Administrator. The facility's policy required coordinated investigation efforts between Risk Management and Human Resources, including documentation of all steps, interviews with involved parties, and maintenance of records in the designated reporting system. The investigation was not adequately monitored by either the HR Department or Risk Management to ensure all procedural steps were completed and documented. The Clinical Risk Manager relied on verbal updates from the CNO and did not review the investigation documentation or ensure that all required steps were followed. The HR Director provided only verbal guidance and was not directly involved in the investigation or documentation process. Additionally, the facility did not have a functioning grievance committee as required by its own policy, and all grievances were being addressed in the Quality Assurance and Performance Improvement (QAPI) committee. The lack of oversight and incomplete documentation resulted in an inadequate investigation of the abuse allegation and failure to follow up on additional concerns raised by other residents. This placed all residents at risk for suboptimal investigations of complaints and grievances.
Failure to Timely Report Investigation Results of Abuse Allegation
Penalty
Summary
The facility failed to report the results of an investigation into an allegation of verbal abuse to the State Agency within the required 5 working days, as mandated by CFR 483.12(c)(4). An incident was initially reported by the Chief Nursing Officer (CNO), who stated that she faxed the final report to the State Agency. However, when asked, the CNO could not provide proof of this fax, and a review of the State Agency's records showed no receipt of the final report. The only documentation available was an Adult Protective Services Intake Report, which was labeled as an initial report and did not include the results of the investigation. Facility policy required that the results of the investigation be submitted in writing to the State Agency within five days of the initial report. The policy also clarified that while initial reports should be sent to both the State Agency and the Division of Senior Services, only the State Agency required follow-up with the investigation results. The failure to provide the investigation results in a timely and verifiable manner prevented the State Agency from accurately assessing and investigating the allegation, affecting all residents in the facility.
Float and Travel Nursing Staff Lacked Required LTC Competency Training
Penalty
Summary
The facility failed to ensure that float and travel nursing staff possessed the necessary job-specific competencies and skill sets required to care for long-term care (LTC) residents. Record review revealed that a significant number of float and travel nursing staff did not have current LTC training in key areas, including Activities of Daily Living (ADL) Coding and Definitions, Behavioral Health (BH), Quality Assurance Performance Improvement (QAPI), Dementia care, and Trauma Informed Care. Specifically, out of 20 nursing staff personnel files reviewed, 17 lacked current training in ADL Coding and Definitions, BH, QAPI, and Trauma Informed Care, while 11 lacked current training in Dementia care for LTC. Interviews with facility staff, including the Clinical Nurse Educator and House Supervisor, confirmed that the only tracked and required training for float staff assigned to the LTC unit was related to abuse and neglect. The Clinical Nurse Educator was unaware of the requirement for dementia-specific modules, and float staff did not complete the same training as core LTC staff. One float nurse stated that only general orientation was provided, with no education on dementia care, trauma-informed care, or cultural competency prior to working in the LTC unit. Review of facility policies and training modules showed that the facility had established training programs for ADL coding, behavioral health, QAPI, dementia care, and trauma-informed care, all of which are critical for providing appropriate care to LTC residents. The facility assessment indicated that a majority of residents required assistance with ADLs and that several residents had behavioral health conditions, including dementia, depression, anxiety disorders, schizophrenia, and PTSD. Despite these needs, the lack of required training for float and travel staff placed all residents at risk of not receiving the necessary specific treatment and care to attain or maintain their highest practicable well-being.
Failure to Annually Update Facility Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was reviewed and updated annually. Record review showed that the most recent update to the facility assessment was on 5/21/24. During an interview, the Chief Nursing Officer (CNO) confirmed that the facility assessment needed to be updated. This lapse had the potential to affect all residents in the facility, which had a census of 26 at the time of the survey.
Float CNAs Lacked Required Annual Training in Dementia Care and Abuse Prevention
Penalty
Summary
The facility failed to ensure that four float CNAs received the required 12 hours of annual in-service training, including education on dementia care and abuse/neglect prevention. Record review showed that two CNAs had expired training and two had not completed the required training. Despite working in the LTC unit, these float CNAs did not attend the annual educational retreats provided to regular LTC CNAs and only completed an online module focused on abuse and neglect, which did not include dementia care. Interviews with the DON, House Supervisor, and Clinical Nurse Educator confirmed that float staff were not provided with LTC-specific training beyond the abuse and neglect module, and that dementia care education was not tracked or provided for these staff members. The facility's own training records and staff interviews revealed that the float CNAs worked in the LTC unit without having completed the necessary annual training. The facility's adopted training modules for dementia care and abuse/neglect were not utilized for float CNAs, and the continuing education program for these staff did not cover the required topics. This lack of training placed all residents at risk for substandard care due to staff not being provided with the education necessary to ensure continuing competence in the care of LTC residents.
Failure to Thoroughly Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse made by a resident against the Administrator. The resident reported feeling verbally abused after being told by the Administrator that they would never get out of their wheelchair, were a failure, and would die in the facility. The resident was visibly distressed when recounting the incident, but could not recall the exact date it occurred, only that it was before a resident council meeting. The Chief Nursing Officer (CNO) initiated a state report and placed the Administrator on administrative leave, but did not accurately interview the resident to clarify the nature and timing of the allegation. Additionally, there was no documentation of the interview with the resident, and the CNO assumed the incident occurred during the council meeting without confirming this with the resident. The investigation was further compromised by the lack of documentation of an interview with the Administrator, despite the CNO stating that a conversation had occurred. The CNO also failed to contact the resident's provider regarding the abuse allegation, as required by facility policy. During the investigation, the CNO had another nurse interview five additional residents to assess for further concerns, but did not document these interviews thoroughly. Two of these residents reported feeling verbally abused by the Administrator, but their comments were not investigated further. Facility policies require immediate response and thorough investigation of abuse allegations, including contacting the resident's provider, interviewing all relevant witnesses, and documenting findings. In this case, the investigation was incomplete due to failure to clarify the allegation, lack of documentation, and failure to follow up on additional reports of abuse from other residents. As a result, the investigation did not address all potential instances of abuse and did not ensure the safety and rights of the residents involved.
Failure to Provide Resident-Centered Activity Program and Outings
Penalty
Summary
The facility failed to provide an ongoing, resident-centered activity program aligned with individual care plans for 17 residents who enjoyed activities outside of their rooms. The deficiency was identified through record review, interviews, and observations, which revealed that scheduled activities listed on the facility's monthly activity calendar for July, August, and September were not consistently provided. There were multiple documented instances where activities were cancelled or not offered, such as chair yoga and cooking groups, due to staff being pulled to provide direct resident care or because of administrative decisions. The activity department was frequently closed or partially closed, and staff reported being reassigned to other duties, resulting in the cancellation of planned activities. Residents expressed disappointment and sadness over the lack of activities and outings, with several stating that they missed specific events like balloon toss, Walmart trips, and community outings. Residents with dementia were specifically excluded from outings, despite their care plans not requiring 1:1 supervision and their history of safely attending such events. Staff interviews confirmed that the administrator prohibited residents with dementia from participating in outings, and also restricted the use of the facility van for outings due to staffing and financial concerns. Additionally, cooking groups were cancelled by the administrator, citing concerns about food usage and meal planning. The facility's own policies required the provision of meaningful, age-appropriate activities, including outings and special events, to meet the needs and preferences of all residents, including those with dementia. However, the report documents that these policies were not followed, and residents' individualized activity preferences, as outlined in their care plans, were not honored. The lack of consistent activity programming and outings led to residents feeling isolated, bored, and unhappy, as directly stated in their interviews.
Failure to Respect Resident's Rights Regarding Personal Belongings
Penalty
Summary
The facility failed to treat a resident with dignity and respect when the Administrator took possession of the resident's personal checkbook against the resident's wishes. The Administrator, accompanied by a nurse, entered the resident's room and requested the checkbook, citing the need to assist with Medicaid application and concerns from the resident's Power of Attorney (POA) regarding unauthorized check writing. Despite the resident's initial refusal and expressed anger, the Administrator persisted, and the resident eventually surrendered the checkbook after being assured they would be informed if any checks were written while it was in the Administrator's possession. After obtaining the checkbook, the Administrator stored it in her personal desk rather than the facility's resident safe, stating she was unfamiliar with the safe's process. The checkbook remained in the Administrator's desk over a weekend, and the Administrator left for a family emergency before transferring the checkbook to the POA. During this period, the resident requested the return of the checkbook, and staff members observed the resident's distress and the Administrator's dismissive behavior toward both the resident and staff present during these interactions. There was no documentation in the resident's medical record regarding the Administrator's discussions with the POA, the interaction with the resident, the storage of the checkbook, or the plan for its return. The facility's policies on patient rights and resident responsibilities emphasize the right to dignity, respect, and the ability to keep personal belongings safe, which were not upheld in this instance. The actions taken by the Administrator were not in line with usual facility practice, as confirmed by other staff interviews.
Failure to Manage Resident's Blood Glucose Levels
Penalty
Summary
The facility failed to manage the blood glucose levels of a resident with Type 1 Diabetes Mellitus, leading to significant fluctuations in their blood sugar levels. The resident, who was previously managing their diabetes with an insulin pump and continuous glucose monitoring system at home, experienced blood glucose levels ranging from 52 to 468 mg/dL after admission to the facility. These fluctuations resulted in symptoms such as fatigue, headaches, and an inability to participate in daily activities and occupational therapy sessions. The resident's medical history included Type 1 Diabetes Mellitus, diabetic polyneuropathy, severe protein malnutrition, chronic kidney disease, and Parkinson's Disease. Upon admission, the resident's insulin pump was discontinued, and the facility attempted to manage their diabetes with basal and short-acting insulin. However, the facility's management of the resident's blood glucose levels was inconsistent, with frequent episodes of both hyperglycemia and hypoglycemia, which were not effectively addressed. Interviews with the resident, their spouse, and facility staff revealed concerns about the resident's unstable blood glucose levels and the impact on their physical and mental well-being. The resident's spouse expressed worry about the potential effects of high blood sugar levels on the resident's vision, while the medical director acknowledged the difficulty in managing the resident's blood glucose levels since admission. The facility's failure to provide consistent and effective diabetes management compromised the resident's ability to maintain their highest practicable physical and mental well-being.
Failure to Manage Blood Glucose Levels in Diabetic Resident
Penalty
Summary
The facility failed to manage the blood glucose levels of a resident with Type 1 Diabetes Mellitus, leading to significant fluctuations in their blood sugar levels. The resident, who was previously managing their diabetes with an insulin pump and continuous glucose monitoring system at home, experienced blood glucose levels ranging from 52 to 468 mg/dL after admission to the facility. These fluctuations were not adequately addressed, as evidenced by the lack of timely adjustments to insulin dosages and dietary management, despite the resident's history of stable blood glucose control at home. The resident's medical history included Type 1 Diabetes Mellitus, diabetic polyneuropathy, severe protein malnutrition, chronic kidney disease, and Parkinson's Disease. Upon admission, the resident's insulin pump was discontinued, and the facility's management of their diabetes relied on basal insulin and sliding scale insulin orders. However, the facility's approach did not prevent significant blood glucose fluctuations, resulting in episodes of hypoglycemia and hyperglycemia, which were not consistently managed according to the facility's hypoglycemia protocol. The resident experienced physical and psychosocial well-being issues due to the unmanaged blood glucose levels, including fatigue, headaches, and an inability to participate in occupational therapy sessions. Interviews with the resident, their spouse, and facility staff highlighted concerns about the resident's unstable blood glucose levels and the impact on their health and daily activities. Despite these concerns, the facility did not provide adequate documentation or physician notes to demonstrate effective management of the resident's diabetes, contributing to the deficiency in care.
Failure to Update Care Plans for Anticoagulant Use and Chronic Pain
Penalty
Summary
The facility failed to update and revise the care plans for two residents, which resulted in deficiencies in their care. Resident #1, who was admitted with diagnoses including atrial fibrillation, heart failure, and diabetes, was prescribed Apixaban, an anticoagulant medication, starting on 12/17/24. However, the care plan did not reflect the ongoing use of this high-risk medication after it was removed on 1/28/25, despite the resident continuing to take it. This oversight meant that staff were not alerted to the potential risks and side effects associated with the anticoagulant, which could have impacted the resident's care. Resident #19 was admitted with a subdural hematoma and a fracture requiring a right total knee replacement. The resident reported chronic right shoulder pain since admission, which was documented in various progress and nursing notes. Despite these reports, the care plan did not include the resident's right shoulder pain, which was a significant oversight given the resident's ongoing complaints and the need for pain management interventions. The MDS Coordinator acknowledged the omission and stated that the care plan should have included the shoulder pain. The facility's policy on care planning emphasizes the need for a dynamic and continually updated care plan based on the assessed needs of the resident. The failure to update the care plans for these residents indicates a lapse in adhering to this policy, potentially affecting the quality of care provided. The MDS Coordinator and the Director of Nursing are responsible for ensuring that care plans are comprehensive and reflective of the residents' current conditions, but in these cases, the necessary updates were not made in a timely manner.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility failed to provide a program of meaningful activities for a resident based on an individualized assessment and care plan. The resident, who had diagnoses including pressure injury, post-surgical hip fracture repair, anxiety disorder, schizoaffective disorder bipolar type, and moderate Alzheimer's dementia, expressed that the activities offered did not appeal to him/her. The resident preferred listening to music, going to specific stores, and avoiding large crowds, but these preferences were not discussed or incorporated into the activities program by the facility staff. The Activity Coordinator (AC) admitted that an activities program was not developed for the resident and that the resident's preferences were not documented. The AC's activity assessment folder did not include the resident, and the only activity related to the resident's care plan was a service dog visit. The Long-Term Care (LTC) Administrator confirmed that the resident's activity preferences were supposed to be included in the care plan but were not. An initial activity assessment for the resident was only completed on the last day of the survey, indicating a significant delay in addressing the resident's needs.
Failure to Provide Ordered Restorative Exercises
Penalty
Summary
The facility failed to ensure that a resident received the ordered restorative exercises, which placed the resident at risk of not maintaining or improving their range of motion and mobility. The resident, who was admitted with diagnoses including primary osteoarthritis of both knees, bilateral leg swelling, and weakness of both lower extremities, reported not remembering the last time they had physical therapy. The active order dated 2/9/24 specified exercises including ankle pumps and hip reductions, but the resident's care plan and restorative aide documentation revealed that only ankle pumps were provided, and hip reductions were not performed. Additionally, no restorative exercises were provided from 3/7/24 to 3/14/24. Interviews with the restorative aide and review of the electronic health record confirmed that the aide only provided ankle pumps due to a documentation issue where the full order did not appear in the system. The facility administrator acknowledged that there was no policy regarding restorative exercises. This oversight resulted in the resident not receiving the full scope of prescribed restorative exercises, potentially impacting their ability to maintain or improve their physical condition.
Failure to Post Accurate Staffing Hours
Penalty
Summary
The facility failed to post the total number and actual hours worked by Certified Nurse Assistants (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) per shift. This deficiency was identified during an observation on 3/15/24 at 9:20 AM, where the posted staffing information did not include the required details. During an interview, the Unit Clerk (UC) confirmed that the total staffing hours were posted per day and were assumed to be the same as the actual work hours, as the facility provided coverage as needed. The UC was unaware that the actual and total hours per shift were required to be posted. A review of the Daily Staffing Sheet from 3/11-14/24 also showed that the actual and total hours per shift were not documented.
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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