Polaris Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Anchorage, Alaska.
- Location
- 920 Compassion Circle, Anchorage, Alaska 99504
- CMS Provider Number
- 025036
- Inspections on file
- 25
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Polaris Extended Care during CMS and state inspections, most recent first.
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 experienced harm due to the facility's failure to provide timely wound care and respond appropriately to changes in condition. One resident did not receive scheduled wound treatments or adequate assessment of increased pain, leading to wound infection and adverse effects from antibiotics. Another resident with a recent pacemaker procedure had a change in the surgical site that was not promptly escalated to the wound care team, resulting in infection, hospitalization, and surgical intervention.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to proper transition planning.
A CNA was witnessed striking a resident and making a derogatory comment about incontinence. The incident was not reported to facility leadership until over a month later, and while APS was notified promptly, the State Agency was not informed in a timely manner. The final report was sent to an incorrect email address, resulting in the State Agency only learning of the incident through the Ombudsman. Facility policy requiring immediate reporting to the State Survey Agency was not followed.
Several residents did not receive timely assistance with ADLs, including bathing and toileting, due to inadequate staffing, resulting in discomfort and emotional distress. Two residents missed multiple doses of essential medications, such as sodium bicarbonate and anti-seizure drugs, because the medications were not available or not properly managed. Another resident experienced prolonged pain and delayed treatment for UTI symptoms due to repeated failures in obtaining and processing urine samples, with no timely provider follow-up after abnormal lab results.
A resident with a history of lymphoma, myasthenia gravis, and polyuria experienced prolonged UTI symptoms, including bladder pain and painful urination, for over a month. Despite repeated requests for urine testing and ongoing symptoms, there were multiple failures in obtaining and processing urine samples, delays in provider assessment, and inadequate communication. The resident's pain and discomfort persisted due to the lack of timely and appropriate care.
The facility did not provide residents with clear or consistent instructions on how to file grievances, and information about the grievance officer was inaccurate or unknown to residents. Signage and documents contained conflicting contact details, and staff interviews revealed confusion about the grievance process and oversight. Some residents expressed fear of retaliation, and grievances were not always formally documented or addressed in QAPI meetings.
The facility did not complete required activity admission evaluations for several new residents, failed to ensure proper oversight and supervision of the activities program, and lacked a method to document specific resident participation in activities. As a result, residents' activity preferences were not consistently assessed or accessible to care staff, and the effectiveness of the activities program could not be evaluated.
The facility was cited for a medication error rate of 23.08% after surveyors observed multiple errors, including administration of oral medications via G-tube without updated orders, improper subcutaneous insulin injection technique, failure to correctly identify and withhold a blood pressure medication per parameters, and not instructing a resident to chew chewable tablets. These actions were inconsistent with physician orders and facility policy.
The facility did not ensure that all staff involved in food preparation and service, including CNAs, nurses, and cooks, maintained current food handler cards. Many staff had expired or missing cards, and the facility lacked clear policies and oversight for tracking and renewing these credentials. As a result, unqualified individuals were involved in preparing and serving food to residents.
Residents experienced prolonged periods without nourishment due to closely scheduled meal times and lack of consistent access to snacks after kitchen hours. Some residents had to request snacks before kitchen staff left, while others were unaware of available options or resorted to ordering outside food. Staff relied on informal communication and outdated policies, and there was no clear process for documenting resident preferences or ensuring access to suitable snacks outside scheduled meal times.
Staff assigned to provide direct resident care in two cottages were found to lack current training and competency validation. A Rehabilitation Aide was assigned CNA duties without recent experience or up-to-date training, and an MDS Nurse provided incontinence care without documented competency or prior CNA experience. These deficiencies affected multiple residents and were not consistent with the facility's stated training and competency protocols.
The facility allowed numerous employees and contracted staff, including clinical, administrative, and support personnel, to work without valid Alaska background checks as required by state regulations. Both new hires and established staff, as well as travel staff, began working or continued employment without proper clearance, with some lacking background checks for several weeks or months. This failure occurred despite the facility's stated policy and was identified through record review and staff interviews.
Multiple residents did not receive care as outlined in their care plans, including missed scheduled showers, inadequate assistance during mechanical lift transfers, and insufficient repositioning for those at risk of pressure injuries. One resident with COPD did not have a care plan addressing their diagnosis, despite having related medication orders. Staff interviews and documentation confirmed these deficiencies, which were attributed in part to staffing shortages.
Surveyors identified multiple deficiencies, including failure to follow individualized turning and repositioning schedules for residents with impaired mobility, inaccurate wound assessments and documentation, improper administration of enteral nutrition and medications, and significant delays in incontinence care. For example, a resident was left in the same position for hours despite care plans, wounds were not documented or treated as ordered, enteral feeding protocols were not followed, and a resident waited over three hours for hygiene care.
Surveyors found expired and unlabeled medications and medical supplies in multiple medication and treatment carts, including glucose control solutions, test strips, laxatives, oral rinses, topical antibiotics, dressings, hydrogen peroxide, and sterile water. Staff interviews confirmed that these items should have been labeled with open dates and removed once expired, but this was not consistently done.
Surveyors found that the facility failed to maintain complete and accurate medical records, including missing provider orders for oxygen therapy, inaccurate dates on psychotropic medication consent forms, and incomplete documentation of dietary assessments. Staff confirmed that some treatments were provided without proper orders, consent forms were signed on dates different from those recorded, and handwritten notes were added to assessments without proper dating or inclusion in the electronic record.
Several residents with significant physical and mental health needs were not provided with scheduled showers, timely transfers, or opportunities to participate in activities due to ongoing staffing shortages. Residents reported missed showers, long waits for assistance with hygiene and transfers, and inability to attend activities or go outside as care planned. Staff interviews and documentation confirmed that inadequate staffing led to these failures, directly impacting residents' ability to make choices about their daily lives.
Multiple residents did not receive scheduled showers, timely incontinence care, or regular turning and repositioning due to insufficient nursing staff. Some residents missed opportunities to participate in activities or receive assistance with transfers, and documentation showed significant delays in care. Staff interviews confirmed that short staffing prevented the delivery of care as outlined in resident care plans and facility policy.
A resident with severe dementia and multiple health conditions was admitted, and their representative was pressured to sign a SNF ABN form without adequate explanation or information about appeal rights. The facility did not clearly communicate the care plan or treatment options, leading to confusion about eligibility for skilled therapy versus LTC. The representative's attempts to seek clarification were unsuccessful, and a grievance was not properly logged or addressed, violating the right to be fully informed and to participate in care decisions.
A resident with limited mobility and cognitive impairment was found unable to access their call light, as it was placed out of reach and sight, leading the resident to call out for help. The facility's policy requires staff to keep call lights within reach, but this was not consistently followed, as confirmed by the DON.
A resident with legal blindness was unable to access a $200.00 deposit intended for their trust account because the funds were mistakenly placed in a general account rather than the resident's individual trust account. The error was confirmed through record review and staff interviews, and the resident was not able to manage or access their personal funds as required by facility policy.
Two residents were not provided with required written bed hold notifications at the time of hospital transfer, and a physician's discharge order was missing for one resident. Interviews with staff confirmed the absence of these documents, and facility policy requiring written notification and documentation was not followed, resulting in incomplete records and lack of communication about bed hold rights.
Three dependent residents did not receive scheduled assistance with bathing and oral hygiene as outlined in their care plans, due to inadequate staffing and failure to follow facility policies. Documentation and interviews confirmed that showers and oral care were missed or delayed, and residents reported discomfort and dissatisfaction with their hygiene care.
Three residents did not receive proper pressure ulcer prevention and care, including missed wound assessments, lack of wound documentation, and failure to consistently turn and reposition residents as required by care plans and facility policy. Staff were unaware of existing wounds, and ordered wound care interventions were not implemented, resulting in inadequate monitoring and increased risk for skin breakdown.
A resident requiring two-person assistance for transfers due to significant neurological and physical impairments was left suspended in a ceiling lift without adequate supervision when a CNA attempted a solo transfer and left the resident alone to seek help after the lift malfunctioned. This action was not in accordance with the resident's care plan or facility policy.
Staff failed to follow safe enteral nutrition practices for two residents, including not checking gastric residuals, not maintaining proper head-of-bed elevation during feeding, not flushing feeding tubes as ordered, and using uncapped, potentially contaminated tubing. These actions did not comply with facility policy or standard procedures.
The facility did not ensure that supplemental oxygen therapy was properly ordered and monitored for three residents with respiratory needs. Two residents did not have consistent documentation of oxygen saturation levels as required, and two residents received oxygen therapy without a physician's order. The DON and medical director confirmed these deficiencies, and facility policy requires both provider orders and regular monitoring for oxygen therapy.
The facility did not obtain or document provider orders for oxygen therapy for two residents, despite evidence of ongoing oxygen use, and failed to secure a physician order for dental services for another resident experiencing dental pain. Staff interviews and record reviews confirmed the absence of required orders and a lack of follow-through on care requests, contrary to facility policy.
Nursing staff failed to follow physician orders and professional standards in medication administration, enteral feeding, and infection control for three residents. This included administering medication outside of ordered parameters, using non-approved equipment, not checking gastric residuals, improper bed positioning during feeding, failing to maintain sterility during tracheostomy care, and using potentially contaminated enteral tubing. These actions led to an adverse outcome of low blood pressure for a resident and placed others at risk for aspiration, infection, and medication errors.
A resident with multiple psychiatric diagnoses was prescribed Seroquel, and the pharmacist recommended updating the associated diagnosis to bipolar disorder. Although the order was changed, there was no documented review or response from the physician or medical director to the pharmacist's recommendation, as required by facility policy.
Multiple residents experienced significant medication errors, including improper insulin injection technique, repeated missed doses of essential medications due to unavailability, and administration of blood pressure medication outside of ordered parameters. These errors resulted in adverse reactions, such as low blood pressure and increased risk of complications, and were confirmed through record review, observation, and interviews with staff and residents.
A resident with significant dental issues and intermittent pain requested a dental appointment, but no follow-up or scheduling occurred due to lack of physician orders and staff awareness. Despite documentation of the need for dental care, the facility did not assist in arranging necessary dental services as required by policy.
Staff failed to follow food safety protocols by leaving cooked food uncovered, not practicing proper hand hygiene or glove use during food preparation, and not maintaining required food temperatures. These actions included serving food that was left uncovered on the stove, handling food and kitchen equipment with the same gloves, and not checking or maintaining food temperatures before serving meals to residents.
Surveyors identified multiple infection control failures, including improper handling of a urinary catheter drainage bag, breaches in sterile technique during tracheostomy care, failure to use required PPE for droplet precautions, unsafe practices during enteral tube feeding, and unsanitary food handling by dietary staff. These actions were observed across several residents and departments, with staff and infection preventionist interviews confirming the lapses.
Three residents experienced failures in dignity and timely care: one had a urinary catheter drainage bag covered with a trashcan liner and hung inappropriately, another was turned in bed without a lifting sheet and with force, causing discomfort, and a third waited over three hours for incontinence care after requesting assistance. These actions did not follow care plans or facility policies regarding resident rights and dignity.
A facility-wide assessment was found to be outdated and incomplete, missing translation services for non-English speaking residents, containing inaccurate information about a staffing waiver, and listing outdated or missing vendor contacts, including the contracted physician group. These deficiencies were confirmed through record review and administrator interviews.
A resident with severe pain and multiple serious diagnoses experienced an eight-hour delay in receiving Morphine due to medication supply shortages, communication errors with the contracted pharmacy, and procedural barriers for accessing controlled substances. The resident reported significant pain and distress during this period, as nurses were unable to obtain the necessary medication in a timely manner.
A resident with complex medical needs, including myasthenia gravis and chronic pain, experienced significant delays in receiving prescribed Morphine and Pyridostigmine due to medication shortages and late administration by nursing staff. These delays led to unmanaged pain and respiratory distress, with documentation inconsistencies noted in the medication administration records.
Medication carts in two cottages were repeatedly left unlocked and unattended by LNs, including times when narcotic drawers were open and the main lock was not engaged. The carts were left unsupervised in community spaces, and staff acknowledged that carts should only be unlocked when within eyesight, but this protocol was not consistently followed. The DON confirmed that facility policy requires medication carts to be locked when not in sight of authorized staff.
A resident with chronic kidney disease, hypertension, and diabetes repeatedly requested to be seen by an MD instead of an NP, but their preference was not communicated to leadership or documented. The issue was only addressed after the resident escalated the matter, leading to a visit from an MD and a nephrology appointment. The facility's policy on resident rights was not followed, resulting in a delay in meeting the resident's healthcare preferences.
A resident with stage 3b chronic kidney disease, hypertension, and diabetes did not receive regular nephrology follow-up care as recommended. Despite the resident's requests since April, the last nephrology appointment was in December of the previous year, and no nephrology orders were documented. The nurse practitioner overseeing the resident's care since June did not monitor nephrology needs or request records. The facility only recognized the need for nephrology care in October, scheduling an appointment for January.
The facility failed to maintain adequate staffing levels, resulting in harm to residents who developed severe pressure ulcers due to insufficient care. With a census of 93 residents, the facility operated at crisis staffing levels, leading to delays in care and unmet personal care preferences. Non-nursing staff were trained to assist, but residents and families expressed grievances about the inadequate care. The facility's pressure ulcer rate was significantly higher than the national average, and the administration was aware of the staffing challenges impacting residents' well-being.
The facility administration failed to manage resources effectively, resulting in substandard care and harm to residents. Staffing shortages led to delays in care, contributing to the development and deterioration of pressure ulcers. Attempts to mitigate staffing issues by training other staff were ineffective, and residents expressed feelings of hopelessness and frustration.
The facility failed to provide adequate care and services to residents due to staffing shortages, resulting in psychosocial harm and unmet needs. Residents reported discomfort with male caregivers, cold meals in disposable containers, and delays in personal hygiene and care routines. The staffing crisis, with only one CNA per cottage, led to unmet needs and dissatisfaction among residents, impacting their quality of life and well-being.
The facility failed to provide adequate support for residents' Activities of Daily Living (ADLs) due to staffing shortages, leading to psychosocial harm. Residents experienced delays in care, such as bathing, toileting, and transferring, and reported discomfort with male caregivers. Staffing issues resulted in unmet personal care needs and long wait times for assistance, affecting residents' well-being.
The facility failed to protect residents by not removing alleged perpetrators during abuse investigations. A resident reported being hit by an LN, who continued working despite the allegation. Another resident experienced distress when a CNA, previously reported for throwing a nightshirt at them, returned to work in their area. These actions violated the facility's policy to protect residents during abuse investigations.
The facility failed to have a full-time Director of Nursing (DON) from late June to mid-July, with the DON working limited hours and being available remotely. This absence of full-time oversight placed 93 residents at risk for subquality care. The Quality Director was designated as interim DON until a new DON could start.
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 Provide Timely Wound Care and Change in Condition Response
Penalty
Summary
The facility failed to provide necessary care and services to two residents, resulting in harm. For one resident with a history of myasthenia gravis, lymphoma, immunodeficiency, asthma, and chronic respiratory failure, the facility did not administer scheduled wound treatments and dressing changes for abscesses on the right thigh and buttock on two specific dates. Although the electronic Treatment Administration Record (eTAR) was signed off as if the treatments were completed, interviews and documentation revealed that the dressings were not changed, and the wounds were not visually assessed during that period. The resident reported increased pain, which was only addressed with PRN pain medication, without further assessment or escalation to the wound care team or provider. When the wound care team finally assessed the wounds, they found significant infection and deterioration, requiring painful debridement and intravenous antibiotics, which caused additional adverse effects due to the resident's underlying conditions. Another resident, who had a pacemaker implanted and a recent generator replacement, experienced a change in the surgical site condition, including the development of scabs, erythema, and later, wound dehiscence with purulent drainage. Initial nursing assessments documented the changes and implemented standard wound care, but the wound care team was not immediately notified. The wound care nurse was only brought in several days after the initial change in condition, at which point a significant infection was identified. The resident was subsequently hospitalized for an extended period, required surgical intervention to relocate the pacemaker, and underwent extensive wound therapy. The cardiologist later confirmed that the infection was related to the resident's underlying gall bladder infection and emphasized that immediate notification should have occurred when the wound dehiscence was first noted. Facility policy required regular wound assessments, prompt documentation and intervention for pain, and immediate reporting of changes in condition, including signs of infection or wound deterioration. In both cases, the facility failed to follow these protocols, resulting in delayed interventions, progression of infections, and significant harm to the residents. Documentation showed that scheduled treatments were not completed as ordered, changes in condition were not promptly escalated, and communication with providers and specialized teams was not timely.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident-centered care and safe transition planning.
Failure to Timely Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required under CFR 483.12(c)(1). An incident occurred in which a CNA was witnessed striking a resident on the shoulder and making a derogatory comment about the resident's incontinence. The incident was witnessed by another CNA, who reported it to the nurse on duty at the time, but facility leadership was not made aware of the incident until over a month later. Upon learning of the allegation, the Director of Nursing reported the incident to Adult Protective Services (APS) within the required two-hour timeframe but did not notify the State Agency at that time. The initial report to the State Agency was not submitted, and the final report was sent several days later to an incorrect email address that was not monitored for such reports. As a result, the State Agency was not made aware of the abuse allegation until it was reported by the Office of Long-Term Care Ombudsman. The facility's own policy required immediate reporting of such allegations to both the Administrator and the State Survey Agency, but this procedure was not followed, resulting in a delay in the State Agency's awareness and investigation of the incident.
Failure to Prevent Neglect in ADL Assistance, Medication Administration, and Timely UTI Treatment
Penalty
Summary
The facility failed to protect residents from neglect by not providing necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress for several residents. One resident with significant mobility impairments and at risk for pressure ulcers did not receive timely assistance with activities of daily living (ADLs), including bathing, oral care, and toileting. Documentation and interviews revealed that this resident went without a shower for over a month and had to wait extended periods for perineal care after incontinence episodes, primarily due to insufficient staffing and the need for two staff members to safely transfer the resident using a ceiling lift. The lack of timely and consistent ADL care led to the resident feeling uncomfortable, down, and emotionally distressed. Two other residents did not receive their prescribed medications as ordered. One resident with chronic kidney disease and diabetes missed multiple doses of sodium bicarbonate because the medication was not available in the medication cart, as confirmed by both the resident and medication administration records. Another resident with epilepsy missed several doses of Celotin, an anti-seizure medication, due to repeated unavailability from the pharmacy. This resident and their power of attorney expressed concern about the missed doses, and documentation showed that alternative medications were sometimes used, but not always, and that communication and documentation regarding the missed doses were inconsistent. A fourth resident experienced a significant delay in receiving appropriate and timely treatment for symptoms of a urinary tract infection (UTI). Despite repeated requests and multiple orders for urine analysis (UA), several samples were either not sent to the lab, lost, or contaminated, resulting in a delay of over a month before antibiotics were started. The resident continued to experience pain and discomfort during this period, and there was no evidence that a provider assessed the resident for UTI symptoms after abnormal UA results were received. Facility policies and job descriptions reviewed indicated that the care provided did not meet the required standards for timely and adequate care, medication administration, and follow-up on resident symptoms.
Failure to Provide Timely and Appropriate UTI Care
Penalty
Summary
A resident with a complex medical history, including large B-cell lymphoma, myasthenia gravis, and polyuria, experienced ongoing symptoms suggestive of a urinary tract infection (UTI) for over a month. The resident repeatedly reported symptoms such as bladder pain, painful urination, and flank pain, and made multiple requests for a urine analysis (UA) to be completed. Despite these requests, there were significant delays and failures in obtaining and processing urine samples: the first UA was not sent to the lab, the second was not received or analyzed, the third was contaminated, and the fourth was not processed. Only the fifth UA was successfully analyzed, but it showed abnormalities, and no timely follow-up or re-collection was performed after a contaminated result was reported. Throughout this period, the resident continued to experience pain and discomfort, as documented in progress notes, and was administered pain medications such as ibuprofen and phenazopyridine. The resident also reported that their external catheter (Purewick) was unavailable due to a missing part, which had not yet been replaced. Despite ongoing symptoms and abnormal UA findings, there was no evidence that a provider assessed the resident in response to these concerns until much later, after the Medical Director reviewed the case. The resident and their power of attorney repeatedly sought information and action regarding the UTI symptoms, but communication and follow-up were inadequate. Interviews with facility leadership, including the Director of Nursing and Infection Preventionist, confirmed that there was no documentation of provider follow-up for the resident's UTI symptoms and that multiple urine samples were not processed by the lab. The facility's own policy states that residents have the right to receive adequate and appropriate care, be informed of changes in their medical condition, and participate in their own care planning. These rights were not upheld in this case, as the resident's symptoms were not appropriately or promptly addressed.
Failure to Provide Clear Grievance Process and Officer Information
Penalty
Summary
The facility failed to ensure that residents were provided with clear and consistent instructions on how to file grievances and did not consistently communicate the identity of the grievance officer. Multiple residents interviewed during the survey expressed confusion and lack of awareness regarding the grievance process and the grievance officer, with some stating they had never heard of or met the designated official. Signage and documentation throughout the facility contained inconsistent and inaccurate contact information for the grievance officer, including incorrect email addresses and phone numbers. Additionally, the grievance process described in the Resident Admission Agreement and other facility documents conflicted with the information provided on posted signs and by staff, further contributing to resident confusion. Observations revealed that the signage in the cottages directed residents to submit concerns via a locked box or contact the grievance officer using contact details that were either incomplete or incorrect. The Assistant Administrator confirmed the inaccuracies in the posted information and acknowledged the need for updates. The grievance policy and procedure documents lacked the grievance officer's name and accurate contact information, and the process for tracking and logging grievances was informal and inconsistent, with some grievances not officially documented or logged. The grievance officer reported relying on verbal communication from staff rather than maintaining a formal grievance log. Residents also reported fears of retaliation for raising concerns, and there was a lack of evidence that resident grievances discussed in council meetings were addressed in Quality Assurance and Performance Improvement (QAPI) meetings. Staff training on the grievance process was inconsistent, and the oversight structure for the grievance officer was unclear. The facility's failure to provide clear, accurate, and consistent information about the grievance process and officer denied all residents and their representatives the ability to exercise their rights to file grievances correctly and receive written resolutions.
Failure to Complete Activity Evaluations and Document Resident Participation
Penalty
Summary
The facility failed to develop, implement, and provide appropriate oversight of the activities program to support residents' choices and needs. Specifically, activity admission evaluations were not completed according to the facility's established policy for several newly admitted residents. In some cases, the required Activity - admission Evaluation forms were missing from the medical records, and in one instance, the form was present but left completely blank. The information regarding residents' activity preferences was primarily documented in the Minimum Data Set (MDS) rather than in the designated forms within the medical record, making it inaccessible to CNAs and LNs responsible for implementing activity choices. Oversight of the activities program was lacking, as the Activities Supervisor did not actively oversee the program for the facility, instead focusing on another LTC facility on the same property. The monthly activity calendar was created and implemented by Activities Staff, despite this not being within their job description, and the calendar had not been updated since a change in facility ownership. The Activities Supervisor's job description required planning, developing, organizing, implementing, and directing the activities program, but these responsibilities were not being fulfilled as intended. Additionally, the facility did not have a method to document specific resident participation in each activity offered. The electronic medical record's Point of Care (POC) charting section only allowed for a general, once-daily notation of activity participation by category, without specifying which activities a resident attended. This lack of detailed documentation prevented evaluation of the effectiveness of the activities program and whether it met residents' assessed needs and preferences.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 23.08% error rate observed during medication administration for four residents. For one resident with dysphagia, a nurse administered two medications via G-tube that were ordered to be given orally with applesauce. The nurse stated the resident preferred G-tube administration due to difficulty swallowing, but the physician's orders had not been updated to reflect this route. The Director of Nursing confirmed that nurses are expected to follow the prescribed route and contact the provider for any necessary changes before administration. Another resident with dementia, hemiplegia, and diabetes received a subcutaneous insulin injection in the deltoid muscle area, where there was no visible adipose tissue. The nurse administered the injection at a 90-degree angle into the deltoid, which is not a recommended site for subcutaneous injections due to lack of fatty tissue. Facility reference materials and manufacturer guidelines specify that subcutaneous injections should be given in areas with sufficient adipose tissue, such as the outer arm, thigh, abdomen, hips, buttocks, or upper back. A third resident was administered a group of oral medications mixed in applesauce, including a blood pressure medication with a hold parameter for systolic blood pressure below 110. The nurse initially prepared to administer the medication despite a blood pressure reading of 109, only discarding what was believed to be the correct tablet after being prompted. However, the discarded tablet did not match the appearance of the intended medication, raising concerns that the wrong medication may have been withheld or administered. Additionally, a fourth resident was given chewable medications to swallow whole without being instructed to chew them, contrary to both physician orders and facility policy.
Failure to Ensure Staff Maintain Current Food Handler Cards
Penalty
Summary
The facility failed to ensure that all staff involved in food preparation, distribution, and service maintained current food handler cards, as required. Specifically, out of 44 night shift staff, 10 had expired food handler cards and 14 had no proof of having a card at all. Additionally, among 11 cooks, two had no proof of a food handler card and one had an expired card. The deficiency was identified through interviews and record reviews, which revealed that the facility was unable to provide documentation for many staff members' food handler cards and that expired cards were not being tracked or renewed in a timely manner. The Kitchen Manager was unaware of the expired cards and was unclear about who was responsible for ensuring that staff maintained current food handler cards after a change in facility ownership. Further review of staff schedules showed that both CNAs and nurses working evening and night shifts included individuals with expired or unknown food handler card status. The facility also lacked a clear, written policy for after-hours snack preparation and distribution, relying instead on verbal communication. The only available policy was a copied document from the previous owner, with handwritten amendments and corrections by the current Kitchen Manager. This lack of oversight and documentation resulted in unqualified individuals preparing and serving food to all 75 residents in the facility.
Failure to Provide Consistent Access to Meals and Snacks According to Resident Preferences
Penalty
Summary
The facility failed to ensure that meals and snacks were provided in accordance with residents' needs, preferences, and requests. Residents reported a significant gap of up to 15 hours between dinner and breakfast, with dinner served between 4:15 and 5:00 PM and breakfast at 8:00 AM. Residents had to request snacks before the kitchen staff left at 6:00 PM, or they would go without food until breakfast. Some residents resorted to ordering food from outside the facility due to inconsistent access to after-hours snacks. Observations confirmed that residents did not have independent access to snacks, as kitchen and storage areas were off-limits, and there were no posted instructions on how to obtain food after hours. Residents were also seen storing food in their rooms. Interviews with the Kitchen Manager revealed that while snacks were available by pre-order or could be prepared by LNs, CNAs, or housekeepers, many residents were unaware of these options. The process for assessing resident satisfaction with meal times and snack availability was informal and not consistently documented. There was no formal written policy for late-night or after-hours snacks, and the existing snack tracking system was not consistently used. The only written policy available was a copied document from a previous owner, with handwritten amendments and corrections, indicating a lack of clear, current procedures for ensuring residents' nutritional needs were met outside scheduled meal times.
Staff Training and Competency Deficiencies in Resident Care Assignments
Penalty
Summary
The facility failed to ensure that staff assigned to provide direct resident care in two cottages, Susitna and Nenana, were appropriately trained or had up-to-date competencies. In Nenana Cottage, a Rehabilitation Aide was assigned to work as a CNA despite not having performed CNA duties in over three years. The aide's last documented training for safe patient handling and peri care was nearly a year prior, and there was no current CNA training or competency validation on file. In Susitna Cottage, an MDS Nurse, who had not previously worked as a CNA and had not provided direct patient care in many years, was observed providing incontinence care to a resident. The MDS Nurse did not have documented training or competency in peri care, and the Director of Staff Development confirmed that no nurses had been trained in peri care since assuming their position. These deficiencies were identified through interviews, observations, and record reviews, and affected a total of 23 residents across both cottages. The facility's own assessment stated that all staff are to receive training and demonstrate competencies necessary for resident care, with records maintained and reviewed by the staff development coordinator and QAPI committee. However, the lack of current training and competency validation for staff providing direct care was not consistent with these stated practices.
Failure to Ensure Valid Background Checks for Staff and Contractors
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation screening policy as required by state regulations. Specifically, the facility did not ensure that individuals with direct contact with residents, access to their medical or financial records, or control over their financial well-being had valid criminal history checks conducted under 7 Alaska Administrative Code (AAC) 10.900-10.990. This resulted in 37 employees and 18 contracted staff working without valid clearance from the Alaska Background Check program. The deficiency was identified through record review and interviews, revealing that both new hires and established employees, including those in key roles such as the Administrator, DON, HR Manager, and various clinical and support staff, were working without the required background checks for varying periods, some exceeding two months. For new employees, the HR Manager stated that the hiring process included completion of a State of Alaska background check application and fingerprinting after job acceptance, with the expectation that onboarding would not begin until an eligible background check was received. However, records showed that multiple new hires began orientation, training, and direct resident care before obtaining valid background checks. In some cases, employees worked for several weeks, and in a few instances, over 50 days, before their background checks were completed. Additionally, some staff had background checks associated with other facilities but not with the current facility, as required. For established employees, the transition to new ownership led to further lapses. The facility did not obtain eligibility letters for staff who remained through the change in ownership, and assumed that prior background checks under the old owner were sufficient until new ones were processed. This resulted in several established employees, including those in administrative, clinical, and support roles, working without valid background checks for extended periods. Furthermore, contracted travel staff were also found to be working without the required Alaska State background checks, despite the HR Manager's communication to the parent company about this requirement.
Failure to Implement and Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, resulting in unmet care needs. For two residents with significant mobility impairments, scheduled showers were not provided as care planned. One resident reported receiving only one shower per week instead of the two scheduled, and another stated showers occurred as infrequently as once a month. Documentation confirmed that both residents received fewer showers than care planned, and staff interviews attributed this to short staffing. The care plans for both residents specified assistance with bathing on set days, but these interventions were not consistently carried out. In another instance, a resident requiring a two-person assist for transfers with a ceiling lift was left suspended in the air and unattended when the lift malfunctioned. The CNA involved did not have a second staff member present during the transfer, contrary to the care plan and facility policy, and left the resident alone while seeking help. This was confirmed by observation and staff interviews, which acknowledged the expectation for two-person assistance during such transfers. Additionally, two residents with impaired mobility were not repositioned as frequently as required by their care plans, with observations showing prolonged periods without repositioning and documentation indicating only two repositioning events in a day. One of these residents developed a wound on the hip, which was not properly dressed as ordered. Another resident with a diagnosis of COPD did not have a care plan addressing this condition, despite having provider orders for related medications. Staff interviews confirmed that a care plan for COPD should have been in place. These failures were documented through record reviews, observations, and staff and resident interviews.
Deficiencies in Repositioning, Wound Care, Enteral Nutrition, and Incontinence Care
Penalty
Summary
Multiple deficiencies were identified in the care and services provided to several residents, including failures in implementing individualized turning and repositioning schedules, accurate wound assessment and documentation, proper administration of enteral nutrition and medications, and timely incontinence care. For example, residents with impaired mobility and at risk for pressure injuries were not repositioned according to their care plans and posted schedules, with observations showing prolonged periods in the same position and staff interviews confirming lapses in documentation and practice. In one case, a resident was observed on their back for extended periods over several days, and staff admitted to not documenting repositioning due to a new charting system. Wound care deficiencies were also noted, with two residents having open wounds that were not accurately assessed or documented by nursing staff. Observations revealed visible wounds that were not recorded in weekly skin assessments, and wound care nurses were unaware of their existence until prompted by surveyors. Additionally, a resident with a left hip wound did not have the ordered dressing in place, and the wound was left exposed to friction from an incontinence brief, contrary to physician orders and facility policy. Enteral nutrition and medication administration were not performed in accordance with physician orders and clinical standards for two residents. Staff failed to check gastric residuals before feeding, did not maintain appropriate head-of-bed elevation during feeding, and did not flush feeding tubes with the prescribed amount of water before and after medication administration. In one instance, enteral tubing was left uncapped and undated at the bedside, and staff proceeded to use it after only wiping it with alcohol, despite infection prevention standards. Timely incontinence care was also lacking, with one resident waiting over three hours for assistance after requesting to be changed, and staff interviews confirmed that such delays were not acceptable.
Expired and Unlabeled Medications and Supplies Found in Medication and Treatment Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and timely removal of expired medications and medical supplies in multiple medication and treatment carts. Specifically, in the Aniak medication cart, opened bottles of glucose control solutions and test strips were found without open dates, despite manufacturer instructions requiring discard after a set period post-opening. The Infection Preventionist confirmed that these items should be labeled with open dates and used within a specified timeframe. In the Talkeetna medication cart, several expired medications and test strips were found, including PEG 3350 powder, Chlorhexidine Gluconate oral rinse, Metronidazole gel, and ACCU-CHEK test strips. A nurse stated that expiration dates were supposed to be checked daily. Additionally, the Kenai treatment cart contained expired dressings and hydrogen peroxide, as well as an opened bottle of sterile water for irrigation with no open date. A nurse acknowledged that expired supplies should have been discarded and that opened sterile water should be dated and used within 24 hours. The facility's nurse position description requires maintaining adequate stock levels of medical supplies and equipment, but these observations indicate lapses in following these protocols.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by missing provider orders, inaccurate documentation, and incomplete recordkeeping. For one resident, oxygen therapy was observed in use on multiple occasions, yet there was no provider order for this therapy in the medical record. The care plan referenced supplemental oxygen, but both the Medical Director and DON confirmed that no order existed for this treatment. Another resident also received supplemental oxygen without a corresponding provider order or adequate monitoring of oxygen saturation, as confirmed by both the Medical Director and DON. In addition, the facility did not ensure the accuracy of informed consent documentation for psychotropic medications. Two residents signed consent forms for psychotropic medications on a date that did not match when the forms were actually signed, as both residents stated they signed the forms on a different day than what was documented. The Quality Assurance Coordinator and Medical Director could not confirm the exact date the provider signed the forms, and the Medical Director acknowledged the possibility of signing blank forms. For another resident, a diagnosis was added to a signed informed consent form after the fact, rather than completing a new form, which the Medical Director stated was not appropriate. The facility also failed to ensure that all relevant assessments and documentation were included in the medical record. For one resident, a dietary assessment was completed on paper with handwritten notes added at various times, but these notes were not dated, timed, or initialed, and the assessment was not included in the electronic medical record. The Kitchen Manager confirmed that assessments were often done verbally and that the paper assessment was not part of the official record. The facility's policy required prompt and appropriate entries in the medical record, including authentication of diagnoses, physician orders, and treatment records, but these requirements were not met in the cited cases.
Failure to Support Resident Choice and Self-Determination Due to Staffing Shortages
Penalty
Summary
The facility failed to honor and facilitate resident self-determination and choice for four residents, as evidenced by multiple instances where residents were not given the opportunity to make significant choices about their daily lives. Specifically, residents did not consistently receive showers or baths as scheduled in their care plans, were not transferred in and out of bed upon request, and were unable to participate in activities or go outside as specified in their care plans. These deficiencies were substantiated through record reviews, resident and staff interviews, and direct observations. One resident with diagnoses including dysphagia, rheumatoid arthritis, and depression reported only receiving one shower per week instead of the two scheduled, a fact confirmed by both the resident's POA and a CNA, who cited short staffing as the cause. Documentation showed that showers were missed on several scheduled days over multiple months. Another resident with multiple sclerosis, diabetes, and major depressive disorder stated they only received showers once a month, despite being scheduled for two per week. Documentation confirmed infrequent showers, and the resident was dependent on staff for transfers. A third resident with coronary artery disease, morbid obesity, heart failure, ESRD, and diabetes reported being unable to brush their teeth or access the toilet independently due to lack of staff assistance, resulting in long waits for perineal care and infrequent showers. Documentation supported these claims, showing minimal oral and personal hygiene care provided. A fourth resident with Type 2 diabetes, ESRD, hemiplegia, and PTSD stated they could not be transferred out of bed when requested and missed activities due to insufficient staff. Staff interviews and documentation confirmed that staffing shortages led to delays and omissions in care, directly impacting residents' ability to exercise choice and participate in meaningful activities.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of multiple residents, resulting in missed or delayed essential care and services. Several residents did not receive scheduled showers as outlined in their care plans, with documentation and interviews confirming that some residents received showers only once or twice a month instead of the scheduled two times per week. Staff interviews corroborated that short staffing led to residents waiting until the next scheduled shower day if care could not be provided as planned. One resident reported not receiving a shower for over a month and experiencing significant delays in oral and personal hygiene assistance due to the lack of available staff for transfers requiring two people. Residents dependent on staff for transfers and participation in activities were also affected. One resident was unable to get out of bed to go outside or participate in activities as requested, missing frequent events and experiencing social isolation. Staff confirmed that covering multiple areas due to insufficient staffing made it difficult to provide timely assistance. Another resident experienced a significant delay in incontinence care, waiting over three hours after requesting help, despite facility policy requiring call lights to be answered within 5-10 minutes and peri care to be provided after voids. The DON acknowledged that such wait times were not acceptable. Residents at high risk for pressure injuries did not receive scheduled turning and repositioning interventions. Observations and documentation revealed that some residents remained in the same position for several hours without being repositioned, contrary to care plans and facility policy requiring repositioning every two hours. Staff interviews confirmed that it was not realistic to meet these requirements with the current staffing levels. These failures were observed across multiple residents with significant mobility impairments and complex medical needs, as documented in their care plans and assessments.
Failure to Fully Inform Resident Representative of Care and Treatment Options
Penalty
Summary
The facility failed to fully inform a resident's representative in advance about the care to be provided and available treatment options, resulting in a violation of the resident's and representative's right to be fully informed and to participate in treatment decisions. The resident in question was admitted with multiple complex diagnoses, including severe vascular dementia, spinal stenosis, obstructive sleep apnea, overactive bladder, and major depressive disorder, and was unable to participate in interviews due to cognitive impairment. The representative reported being pressured to sign a Medicare-related form without adequate explanation and was not made aware of the right to appeal the decision to discontinue skilled services. The representative also stated that the facility did not clearly communicate the care plan after admission, leading to confusion about the resident's eligibility for skilled therapy versus long-term care. Interviews revealed that the admissions coordinator confirmed the form in question was a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), which should have been explained by a licensed nurse. However, the representative felt coerced and was denied a copy of the signed form when requested. The representative made multiple attempts to seek clarification in person but was turned away without answers. Documentation showed that the representative's concerns were not addressed, and a grievance was not logged or followed up on, despite the admissions coordinator offering to file one. Further review indicated that the facility's grievance officer only contacted the family after being prompted by the surveyor and had not previously noticed the complaint due to a preference for in-person notifications. The facility's own resident rights documentation states that residents and their representatives have the right to be fully informed of available services, charges, and to participate in care planning and treatment decisions. These rights were not upheld in this instance, as evidenced by the lack of communication, failure to provide necessary information, and inadequate grievance handling.
Call Light Accessibility Not Maintained for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light device was consistently within reach, as required by facility policy. The resident, who had diagnoses including non-Alzheimer's dementia and Parkinson's disease, was documented as having limited range of motion in both upper and lower extremities and required substantial to maximal assistance for bed mobility, transfers, personal hygiene, and toileting. The resident also used a wheelchair for mobility. According to the resident, there were instances at least once a week when the call light was not accessible. During an observation, the resident was found alone in their room, calling out for help, with the call light placed on the opposite side of the bed, out of both vision and reach. An occupational therapist responded to the resident's calls and repositioned the call light within reach upon request. The Director of Nursing confirmed that staff are expected to ensure the call light is always within reach before leaving a resident's room, as outlined in the facility's standards of care policy.
Failure to Deposit Resident Funds into Trust Account
Penalty
Summary
A resident with legal blindness was admitted to the facility and had a $200.00 check deposited by a family member, as evidenced by a receipt dated 3/27/25. However, review of the resident's trust statement and fund management service statement showed that the $200.00 deposit was not recorded in the resident's trust account. The resident reported being unable to access the funds and stated that the last deposit made over a month ago was not available, despite assurances from the facility that the money was accessible. Interviews with the Business Office Manager (BOM) revealed that the $200.00 check was mistakenly deposited into a general account rather than the resident's individual trust account. The BOM acknowledged the error after reviewing the records and confirmed that the funds were not available in the resident's account as required. The facility's policy mandates accurate accounting for each resident's trust account, which was not followed in this instance, resulting in the resident being unable to manage or access their personal funds.
Failure to Provide Bed Hold Notifications and Discharge Documentation
Penalty
Summary
The facility failed to provide required written bed hold notifications to two residents at the time of their transfer to the hospital, as well as failed to document a physician's order for discharge for one resident. For one resident with multiple diagnoses including type 2 diabetes, end stage renal disease, hemiplegia, major depressive disorder, and PTSD, there was no evidence in the record that a bed hold notification was given when the resident was transferred to the hospital. The resident reported not receiving this notification and was informed by the hospital about the risk of losing their LTC bed after three days. Staff interviews confirmed the absence of the required documentation, and the facility was unable to produce the bed hold notice upon request. Additionally, the State Ombudsman was not informed of the resident's discharge to the hospital, as the facility only reported incidents or discharge concerns to the Ombudsman. For another resident with diagnoses including a wedge compression fracture, type 2 diabetes, and nonalcoholic steatohepatitis, the medical record review showed that the resident was transferred and subsequently discharged, but there was no physician's order documenting the discharge. Progress notes indicated that the provider was notified and agreed to send the resident to the ER due to altered mental status, but the required discharge order was not found in the record. The Medical Records Supervisor and DON both confirmed the absence of the physician's discharge order and bed hold notice in the resident's file. Facility policy requires that residents or their representatives be informed in writing of their right to a bed hold both upon admission and prior to transfer, with a provision for notification within 24 hours in emergencies. The review of a blank bed hold notification form confirmed that Medicaid beneficiaries are responsible for bed hold costs and must notify the facility within 24 hours if they wish to exercise this option. Despite these policies, the facility did not provide the required notifications or documentation for the residents in question, resulting in incomplete records and a lack of proper communication regarding bed hold rights.
Failure to Provide Scheduled ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and oral hygiene, for three dependent residents. For one resident with dysphagia, rheumatoid arthritis, and depression, documentation and interviews revealed that showers were not provided as scheduled in the care plan, with the resident receiving only one shower per week or less, despite being care planned for two. Staff interviews confirmed that short-staffing led to missed showers, and the resident’s POA expressed concern about inadequate hygiene care. Another resident with multiple sclerosis, diabetes with neuropathy, and major depressive disorder, who was dependent for shower transfers, reported receiving showers only once a month, contrary to the care plan specifying two showers per week. Documentation showed that showers were provided far less frequently than scheduled, and staff confirmed the resident’s care plan requirements were not met due to staffing shortages. A third resident with coronary artery disease, morbid obesity, heart failure, end stage renal disease, and diabetes, who required assistance for transfers and was at risk for pressure ulcers, did not receive regular showers or oral hygiene. Documentation indicated that showers and oral care were infrequently provided, and the resident reported long waits for peri care and a lack of assistance with oral hygiene supplies. Staff interviews confirmed that inadequate staffing and the need for two staff members for safe transfers contributed to the failure to provide scheduled care. Facility policies reviewed required daily and as-needed ADL care, including bathing and oral hygiene, but these were not consistently followed.
Failure to Prevent and Monitor Pressure Ulcers Due to Inadequate Assessment and Repositioning
Penalty
Summary
The facility failed to provide necessary care and services to prevent and monitor pressure ulcers for three residents. For one resident with multiple diagnoses including dementia, Parkinson's disease, and malnutrition, staff did not accurately assess or document the presence of open wounds on the toes. Despite visible wounds observed by surveyors, weekly skin assessments and care plans did not reflect these findings, and nursing staff were unaware of the wounds until prompted by surveyors. There were no active wound care orders in place, and the care plan interventions were not effectively implemented. Two other residents, both at risk for pressure ulcers due to impaired mobility and other medical conditions, were not consistently turned or repositioned as required by their care plans and facility policy. Observations showed that one resident remained in the same position for three hours without intervention, and another was left in bed for over four hours without repositioning. Documentation confirmed infrequent repositioning, and staff interviews acknowledged that the expected frequency of turning was not met due to staffing issues. Additionally, for one resident with a left hip wound, the ordered intervention to cover the wound with a dry dressing was not followed, and the wound was left exposed to friction from an incontinence brief. Facility policies and standard care references required regular skin inspections and repositioning for residents with dependent mobility, but these standards were not adhered to, resulting in inadequate pressure ulcer prevention and care.
Resident Left Unattended and Suspended in Ceiling Lift During Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of non-traumatic subarachnoid hemorrhage, hemiplegia, and hemiparesis, who required two-person assistance for transfers, was left suspended in a ceiling lift without adequate supervision. During personal care, a CNA attempted to transfer the resident from bed to wheelchair using a ceiling lift. The lift stopped working when the emergency cord was pulled out, leaving the resident suspended in the air. The CNA left the resident alone in this position to seek help, leaving the resident out of sight and without another staff member present, contrary to the care plan and facility policy. The care plan specified that the resident required two-person assistance with mechanical aid for transfers due to cognitive deficits and decreased strength. Observations confirmed that only one CNA was present during the transfer, and the resident attempted to assist by holding the emergency cord while suspended. Facility policy and the lift manufacturer's instructions both emphasized the need for proper assessment and adequate staff support during transfers, which was not followed in this incident.
Failure to Ensure Safe and Appropriate Enteral Nutrition Administration
Penalty
Summary
The facility failed to ensure safe and appropriate administration of enteral nutrition and medication for two residents with feeding tubes. For one resident with diagnoses including atrial fibrillation, dementia, and hemiplegia, staff did not check gastric residual volume prior to starting enteral nutrition, did not maintain the head-of-bed at the required elevation during active feeding, and did not follow physician orders for flushing the feeding tube before and after medication administration. Specifically, the nurse admitted to not checking residuals before feeding, positioned the resident flat while feeding was infusing, and used an incorrect amount of water for flushing the tube. For another resident with cerebral palsy, epilepsy, and a developmental motor disorder, staff used enteral tubing that was left uncapped and undated at the bedside, which had not been properly protected from contamination. Despite the tubing being wiped with alcohol before use, the facility's Infection Preventionist confirmed that uncapped tubing should not be used and should be replaced. These actions were observed during surveyor visits and were not in accordance with facility policy or standard nursing procedures.
Failure to Provide and Monitor Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services for three residents, as evidenced by improper monitoring and lack of physician orders for supplemental oxygen use. One resident with vascular dementia and dependence on supplemental oxygen was observed receiving oxygen via nasal cannula, but medical record review revealed that required oxygen saturation levels were not consistently documented during both day and night shifts. The care plan for this resident specified the need for oxygen saturation checks, but these were not performed as ordered. Another resident with non-Alzheimer's dementia, Parkinson's disease, heart failure, and hypertension was observed receiving humidified oxygen through a nasal cannula. However, there were no provider orders in the medical record authorizing the use of oxygen therapy for this resident, despite the care plan indicating that supplemental oxygen should be administered as ordered. The medical director and DON confirmed the absence of an order for oxygen therapy and acknowledged that oxygen saturations should be monitored for residents on supplemental oxygen. A third resident, who had chronic obstructive pulmonary disease and had passed away prior to the survey, was documented as using continuous oxygen at night, but there were no provider orders for oxygen therapy or monitoring in the medical record. Nursing assessments noted the use of oxygen and recorded oxygen saturation levels, but only one oxygen saturation was documented over a period of nearly two months. The DON confirmed that orders for oxygen therapy should have been in place and that monitoring was insufficient. Facility policy and standard nursing procedures require a provider's order for oxygen therapy and regular monitoring of oxygen saturation, which were not followed in these cases.
Failure to Obtain and Document Provider Orders for Oxygen Therapy and Dental Services
Penalty
Summary
The facility failed to ensure that provider orders were obtained and maintained for specific resident care interventions, including oxygen therapy and dental services, for three residents. For one resident with diagnoses including dementia, Parkinson's disease, heart failure, and hypertension, observations over several days confirmed the use of 2 liters per minute of humidified oxygen via nasal cannula, both during the day and at night. Despite the care plan referencing supplemental oxygen, there was no provider order for oxygen therapy in the medical record. The Medical Director and DON both confirmed the absence of such an order after reviewing the record. Another resident, who had chronic obstructive pulmonary disease and had since passed away, was documented in multiple nursing assessments as receiving oxygen therapy at various times and amounts. However, the medical record did not contain any provider orders for oxygen therapy or for monitoring oxygen saturation during the period the therapy was administered. The DON acknowledged that only one oxygen saturation was recorded during the relevant timeframe and that orders for oxygen therapy should have been in place. A third resident, admitted with legal blindness and dental issues, reported intermittent dental pain and had requested a dental appointment two months prior. A provider's progress note indicated the need to schedule a follow-up dental appointment for extractions, but no physician order for dental services was found in the medical record. Staff interviews revealed a lack of awareness regarding the resident's request and the absence of any scheduled dental appointments. Facility policies required assistance in making dental appointments and providing dental services, but these were not followed as no order was entered.
Failure to Ensure Nursing Staff Competency in Medication Administration, Enteral Feeding, and Infection Control
Penalty
Summary
Licensed nursing staff failed to demonstrate appropriate competencies and skill sets necessary to care for several residents, resulting in significant deviations from professional standards of nursing practice. For one resident with hypertrophic cardiomyopathy, vascular dementia, and hemiplegia, a nurse prepared and attempted to administer Carvedilol despite the resident's systolic blood pressure being below the ordered threshold. The nurse attempted to remove the Carvedilol tablet from a mixture of medications in applesauce but could not confirm the correct tablet was discarded, and subsequently administered the remaining medications. Additionally, the nurse used personal, non-approved blood pressure equipment to monitor the resident, and multiple medication administration errors were documented where Carvedilol was given despite blood pressure or pulse being below ordered parameters. This resulted in the resident experiencing low blood pressure and decreased responsiveness. Another resident with atrial fibrillation, dementia, and hemiplegia did not have gastric residuals checked prior to enteral feeding as required by physician order, and the head of bed was placed flat during active feeding, contrary to standards that require elevation to prevent aspiration. The same nurse failed to flush the feeding tube with the ordered amount of water before and after medication administration. During tracheostomy care for this resident, sterile technique was not maintained, as sterile supplies were placed on a non-sanitized surface and contaminated gloves were used to handle sterile suction tubing. For a third resident with cerebral palsy, epilepsy, and developmental motor disorder, enteral feeding tubing that had been left uncapped and undated was used after only being wiped with an alcohol pad, despite infection control standards requiring new, capped tubing if contamination is suspected. Review of the nurse's competency records showed completion of various trainings and skills fairs, but there was no documented assessment or follow-up regarding concerns about the nurse's ability to use specific equipment, such as the enteral feeding pump. These failures placed residents at risk for aspiration, infection, and medication errors, and resulted in at least one adverse outcome.
Lack of Physician Documentation in Response to Pharmacist's Drug Regimen Review
Penalty
Summary
The facility failed to ensure that drug regimen review irregularities documented by the pharmacist received a documented review and response from the attending physician or medical director for one resident. Specifically, a resident with diagnoses including anxiety disorder, delusional disorder, and bipolar disorder was prescribed Seroquel for bipolar mood disorder. During an April psychopharmacology meeting, the pharmacist recommended changing the diagnosis associated with the Seroquel order from anxiety/delusions to bipolar disorder, and this recommendation was documented in the pharmacy review note. However, the facility was unable to provide any provider notes indicating that the attending physician or medical director reviewed and responded to the pharmacist's recommendation. The medical director confirmed in an interview that he did not document his review or actions regarding the medication diagnosis change, stating only that he changed the order. This lack of documentation failed to meet the facility's requirement for a documented physician response to pharmacist-identified drug regimen review irregularities.
Significant Medication Errors Affecting Multiple Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving four residents. One resident with insulin-dependent diabetes received a subcutaneous insulin injection in the deltoid muscle, an area lacking sufficient adipose tissue for safe subcutaneous administration, contrary to standard nursing procedures. The nurse involved was observed injecting the medication at a 90-degree angle into the deltoid, and both the nurse and nursing supervisor provided inconsistent or incorrect explanations regarding proper subcutaneous injection sites. Another resident with chronic kidney disease and metabolic acidosis experienced repeated missed doses of Sodium Bicarbonate due to the medication not being available in the medication cart. Documentation showed several doses were not administered over multiple days, with notes indicating the medication was missing or not in stock. The resident reported going days without the medication, and the facility's records confirmed the missed administrations. A third resident with hypertrophic cardiomyopathy and vascular dementia was administered Carvedilol despite blood pressure readings below the ordered parameters on several occasions. On one occasion, the nurse attempted to remove the Carvedilol tablet from a mixture of medications in applesauce after being reminded of the hold parameters, but discarded the wrong tablet and proceeded to administer the remaining medications. The resident subsequently experienced low blood pressure and decreased responsiveness. Additionally, a fourth resident with epilepsy missed multiple doses of Celotin due to the medication being unavailable, with documentation and interviews confirming the missed doses and the resident's concern about the impact on seizure control.
Failure to Provide Timely Dental Services for Resident with Dental Pain
Penalty
Summary
A resident with diagnoses including legal blindness and a disorder of teeth and supporting structures reported experiencing intermittent dental pain. The resident had requested a dental appointment approximately two months prior but had not received any follow-up or information regarding the request. Review of the provider's progress note indicated the resident had a broken tooth and poor dentition, with a recommendation to schedule a follow-up appointment for extractions. However, there were no physician orders for dental services documented in the medical record from the time of the provider's note through the survey period. Interviews with facility staff revealed a lack of awareness and action regarding the resident's dental needs. The Health Unit Clerk was unaware of the resident's request and found no dental orders in the chart. A licensed nurse confirmed the resident had previously cancelled dental appointments due to not feeling well but had no upcoming appointments scheduled. The Director of Nursing stated that the physician should have entered the necessary orders for a dental appointment. The facility's policy requires assistance in making dental appointments and provision of dental services, but these steps were not followed for this resident.
Failure to Follow Food Safety Standards in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was prepared, stored, and served in accordance with professional food safety standards in the kitchens of Susitna and Talkeetna Cottages. In Susitna Cottage, a staff member served a cooked chicken and corn mixture to a resident while leaving the remaining pans of food uncovered on the stove. This was observed by a surveyor, and the food remained uncovered for several minutes until it was brought to the attention of a licensed nurse, who then instructed the staff member to cover the food. The Dietary Service Manager confirmed that food should be covered at all times, even if left for only a few minutes, to prevent contamination as outlined in the FDA Food Code. In Talkeetna Cottage, improper hand hygiene and glove use were observed during food preparation for two residents. A staff member wore the same gloves while preparing food, handling used pans and cutting boards, pouring used oil, and then transferring food to plates and trays without changing gloves or performing hand hygiene between tasks. The staff member only removed gloves to wash dishes, not between food handling tasks. The Dietary Service Manager and facility policy both require handwashing before food preparation and between tasks, as well as proper glove use, which was not followed in this instance. Additionally, food temperature control was not maintained in Talkeetna Cottage. Prepared minced and moist foods were left uncovered on the counter for at least 30 minutes without measuring or recording the temperature, and the food was not placed in a warmer as required. Staff interviews revealed inconsistent practices regarding temperature checks and holding procedures. Facility policy and the FDA Food Code require that hot foods be held at 135°F or above and cold foods at 41°F or below, but these standards were not met during the observed meal service.
Multiple Infection Control Failures in Resident Care and Food Service
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in resident care and food service practices. For one resident with a urinary catheter, the drainage bag was repeatedly observed being hung on a trash bin and covered with a transparent trashcan liner, rather than being properly secured to the bed or placed in a wash bin as per facility policy. Both the resident and staff confirmed that this improper practice occurred regularly, and the infection preventionist acknowledged it as an infection control concern. Another resident requiring tracheostomy care was subjected to improper sterile technique. A licensed nurse placed sterile supplies on a non-sanitized surface and, after contaminating sterile gloves with secretions and debris during cleaning, used the same gloves to handle sterile suction tubing that was then inserted into the resident's airway. This practice was not in accordance with the facility's standard, which requires strict sterile technique for tracheostomy care. Additional deficiencies included staff failing to implement appropriate droplet precautions for a resident on isolation for parainfluenza, as staff entered the room without required face shields despite clear signage and policy. In another case, enteral feeding tubing was left uncapped and undated at a resident's bedside, and a nurse attempted to use it after wiping with alcohol, contrary to infection control standards. In the kitchen, food service staff were observed handling food without proper glove use, failing to change gloves between tasks, not wearing required hair or beard coverings, and wiping hands on clothing, all in violation of facility protocols and FDA Food Code requirements.
Failure to Honor Resident Dignity and Timely Care
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect in several instances involving three residents. For one resident with multiple sclerosis and neuromuscular bladder dysfunction, observations revealed that the urinary catheter drainage bag was repeatedly covered with a transparent trashcan liner and hung on inappropriate objects such as a trash bin, making it visible upon room entry. The resident reported that previously used cloth privacy bags were no longer provided, and staff interviews confirmed that trashcan liners were not an acceptable substitute and posed infection control concerns. Facility policy required the use of privacy bags to maintain dignity, which was not followed. Another resident with hemiplegia, atrial fibrillation, and dementia was observed being turned in bed by a CNA without the use of a lifting sheet, contrary to the resident's care plan. The CNA forcefully rotated the resident, causing a facial grimace, despite the care plan specifying the need for gentle handling and the use of a lifting sheet to prevent pain and skin shearing. The care plan also emphasized the importance of asking the resident about pain and ensuring comfort during care. A third resident with a history of stroke and hemiplegia experienced a significant delay in incontinence care. After requesting assistance via the call light, the resident waited over three and a half hours before care was provided, despite staff being notified of the need. The resident expressed feeling unwelcome due to staff comments about frequent call light use. Facility policy required timely assistance with activities of daily living, including toileting, but this was not adhered to in this instance.
Facility Assessment Lacked Accuracy and Current Resource Information
Penalty
Summary
The facility failed to maintain an up-to-date and accurate facility-wide assessment, as required, to determine the necessary resources for competent resident care during both routine operations and emergencies. Record review revealed that the assessment did not include translation services for three non-English speaking residents, despite listing their language needs. Additionally, the assessment contained inaccurate information regarding a staffing waiver for CNA hours, which the facility did not actually possess. The vendor list was also outdated, listing a contact who no longer worked at a medical gas vendor and omitting the facility's contracted physician group. Interviews with the Administrator confirmed these deficiencies, including the absence of translation services in the assessment, outdated vendor contact information, missing contracted physician information, and incorrect details about the staffing waiver. The facility's assessment, dated 2025, was found to be incomplete and not reflective of the current resources and needs of the resident population, potentially impacting the facility's ability to provide appropriate care at all times.
Failure to Provide Timely Pain Medication Due to Medication Supply and Communication Issues
Penalty
Summary
The facility failed to provide routine and as-needed Morphine for a resident with severe pain, resulting in the resident experiencing unrelieved pain for over eight hours. The resident, who had diagnoses including myasthenia gravis with acute exacerbation, diffuse large B-cell lymphoma, chronic respiratory failure, and heart failure, was on hospice care for pain management. The hospice agency did not supply medications, so the facility was responsible for providing all necessary drugs. The resident reported that it was a frequent occurrence for their cottage to run out of medications, requiring nurses to search other cottages for needed drugs. The deficiency occurred after a change in facility ownership, during which the previous owner removed all medication stock, leaving only two weeks of scheduled medications for continuity of care. The new owner contracted with an off-site pharmacy, PharMerica, and used E-kits for emergency medication needs. However, the process for accessing medications from the E-kits required authorization from PharMerica, which involved obtaining a pull code and, for controlled substances like Morphine, a hard copy prescription with a physician's wet signature. On the day of the incident, a fax error prevented timely ordering of additional Morphine, and when the need arose, PharMerica would not authorize access to the E-kit without the required documentation, causing a significant delay. As a result, the resident received a scheduled dose of Morphine at 2:00 AM but was unable to receive an additional requested dose for severe pain until 1:30 PM, waiting over eight hours. During this time, the resident reported pain levels of 5 out of 10 when still and 8 out of 10 when moving, and was also attempting to pass a kidney stone, which increased their discomfort. The delay in medication administration was attributed to late ordering by nurses, communication errors with the pharmacy, and procedural requirements for controlled substances.
Failure to Prevent Significant Medication Errors Resulting in Pain and Distress
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors, resulting in pain and respiratory distress due to delayed and inconsistent medication administration. The resident, who had diagnoses including myasthenia gravis with acute exacerbation, diffuse large B-cell lymphoma, chronic respiratory failure, and heart failure, was also on hospice for pain control. The facility was responsible for providing all medications, as the hospice agency did not supply them. The resident reported frequent occurrences of medication shortages, requiring licensed nurses to search other cottages for medications, which led to delays in receiving prescribed doses. On one occasion, the resident received a scheduled dose of Morphine at 2:00 AM but did not experience adequate pain relief and requested an additional dose at 5:00 AM. The nurses were unable to provide the medication due to lack of supply and only administered the next dose at 1:30 PM, resulting in an 8.5-hour wait. The resident described significant pain during this period, with pain levels increasing when moving. Review of the electronic Medication Administration Record (eMAR) showed that scheduled doses of Morphine and Pyridostigmine (a time-sensitive medication for myasthenia gravis) were repeatedly administered late, sometimes by several hours, and documentation was inconsistent or missing regarding these delays and medication shortages. The resident also reported that delays in receiving Pyridostigmine affected muscle function and breathing, with several doses documented as being given late and outside the prescribed four-hour intervals. The facility's policy required medications to be administered within prescribed time frames and proper documentation, but these standards were not met. Nurse notes did not consistently reflect the late administration or lack of medication on hand, contributing to the deficiency.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts in two cottages, Kenai and Aniak, were repeatedly left unlocked and unattended by licensed nurses. In Kenai Cottage, the medication cart was found with open and unlocked drawers, including the narcotic drawer, while the nurse was not present in the area. The nurse was seen leaving the cart unlocked multiple times, including during lunch breaks and while attending to residents in other rooms. On several occasions, the main lock of the cart was not engaged, and the cart was left unsupervised in community spaces. The nurse acknowledged that the cart should only be left unlocked when within eyesight, but failed to consistently follow this protocol. In Aniak Cottage, similar observations were made where the medication cart was left unlocked and unattended in the hallway, with no staff present in the vicinity. When questioned, the nurse confirmed that the cart should be locked when not in use and proceeded to lock it after being prompted. The Director of Nursing confirmed that medication carts are to be locked when not in sight of authorized staff, as per facility policy. The facility's policy review indicated that only specific staff should have access to the medication carts and that they must be secured when not supervised.
Failure to Honor Resident's Right to Choose Physician
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician, as evidenced by the case of a resident with chronic kidney disease, hypertension, and diabetes. The resident expressed a preference to be seen by a Medical Doctor (MD) rather than a Nurse Practitioner (NP) since their admission. Despite repeated requests to the NP and mentions during care conferences, the resident's preference was not communicated to the facility's leadership or the Medical Director. The resident's requests were not documented in their medical records, and the NP did not take steps to address the resident's preference. The resident's request to see an MD was only addressed after they escalated the issue in October 2024, leading to a visit from an MD and the scheduling of a nephrology appointment. The facility's policy on resident rights, effective July 2024, states that residents have the right to choose their physician and be informed of their health status. However, this policy was not adhered to in the case of the resident, resulting in a delay in meeting their healthcare preferences and needs.
Failure to Ensure Regular Nephrology Follow-Up for Resident with CKD
Penalty
Summary
The facility failed to ensure regular follow-up care by a nephrologist for a resident with stage 3b chronic kidney disease, hypertension, and diabetes. The resident had been asking for a nephrology appointment since April 2024, but no action was taken. A nephrology consultation report from September 2023 recommended follow-up every three months, but the last nephrology appointment was in December 2023. The resident's medical record lacked any nephrology orders or documentation of nephrology care monitoring. The nurse practitioner responsible for the resident's care since June 2024 did not monitor the need for nephrology oversight and had not requested nephrology records. The facility's health information management supervisor confirmed that no documentation of nephrology care was found after a change in medical providers. The facility only became aware of the need for nephrology care when a medical doctor assessed the resident in October 2024, leading to a referral for a nephrology appointment scheduled for January 2025.
Staffing Shortages Lead to Resident Harm and Unmet Care Needs
Penalty
Summary
The facility failed to ensure sufficient staffing levels of Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) to meet the needs of all residents, resulting in harm to residents who developed Stage III, IV, unstageable pressure ulcers, and deep tissue injuries. The facility's census was 93 residents, with varying levels of acuity requiring different levels of assistance for activities of daily living (ADLs) such as bed mobility, transfers, bathing, eating, and toileting. The staffing shortage led to inadequate care, including failure to turn residents every two hours, contributing to the deterioration of pressure ulcers. The Director of Nursing (DON) had reduced hours, and the facility was operating at crisis staffing levels, with one nurse for every 18 residents and one CNA per cottage of 12 residents. The facility attempted to mitigate the staffing shortage by training non-nursing staff, such as home keepers and housekeepers, to assist with certain tasks, but these staff were not considered nursing staff and could not perform all necessary duties. Residents and their families expressed grievances about the staffing shortages, and staff reported challenges in meeting residents' needs promptly, leading to delays in care and unmet preferences for showers and other personal care. The facility's pressure ulcer rate was significantly higher than the national average, and the Quality Assurance and Performance Improvement (QAPI) committee acknowledged that the lack of staffing contributed to this issue. Residents reported dissatisfaction with the care they received, including delays in receiving assistance, unmet preferences for personal care, and feelings of loneliness and neglect. The facility's administration was aware of the staffing challenges and had discussed potential solutions, but the issues persisted, impacting the residents' physical, mental, and psychosocial well-being.
Inadequate Staffing and Resource Management Leads to Resident Harm
Penalty
Summary
The facility administration failed to ensure effective and efficient use of resources, resulting in substandard quality of care and actual physical harm to residents. The facility was unable to maintain compliance with regulatory requirements, leading to the development and deterioration of Stage III, IV, and unstageable pressure ulcers and deep tissue injuries among residents. The administration was aware of these issues but did not implement effective corrective measures, placing all residents at risk for physical and psychosocial harm. The facility's staffing levels were significantly below the required standards, with one nurse for every 18 residents and one CNA for every 12 residents, which was insufficient to meet the residents' needs. This staffing shortage was exacerbated by the absence of a full-time DON and the inability to fill open nursing and CNA positions. The lack of adequate staffing led to delays in resident care, including missed showers and inadequate turning schedules, which contributed to the high rate of pressure ulcers. The facility attempted to mitigate the staffing issues by training home keepers, housekeepers, and activity staff to assist CNAs, but this was not effectively implemented. Observations revealed that these staff members did not assist with bed mobility, transfers, or dining assistance. The facility's Quality Assurance and Performance Improvement committee recognized the impact of staffing shortages on resident care but had not yet implemented effective solutions. Residents expressed feelings of hopelessness and frustration due to the inadequate care and attention they received.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide necessary care and services to residents, resulting in psychosocial harm to ten residents and placing the remaining 83 residents at risk. The report highlights multiple instances where residents' preferences and needs were not honored, leading to feelings of hopelessness, humiliation, and frustration. For example, one resident expressed discomfort with male caregivers providing personal care, which was not respected by the staff. Another resident reported receiving cold meals in disposable containers due to staffing shortages, which affected their dining experience and overall quality of life. Several residents reported issues with personal hygiene and care routines due to inadequate staffing. One resident was unable to receive showers as frequently as desired, while another had to wait extended periods for assistance with toileting, resulting in accidents. The lack of staff also impacted residents' ability to participate in activities, with some residents missing out on social interactions and group activities that were important to them. The facility's staffing crisis, with only one CNA per cottage, led to delays in care and unmet needs, contributing to residents' feelings of neglect and dissatisfaction. The report also notes that the facility's staffing shortages affected the ability to provide timely and adequate care, with staff expressing concerns about the increased workload and inability to meet residents' needs. The facility's administrator acknowledged the staffing challenges and the impact on care quality, but the facility continued to operate at crisis staffing levels. The report includes observations and interviews with residents, staff, and family members, highlighting the widespread impact of staffing issues on residents' well-being and quality of life.
Inadequate ADL Support Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that residents' Activities of Daily Living (ADLs) were adequately supported, leading to psychosocial harm for several residents. The report highlights that the facility did not provide necessary assistance for bathing, dressing, toileting, transferring, bed mobility, and eating for eight residents, as well as two additional residents who did not have their ADL needs met. This deficiency was exacerbated by staffing shortages, which resulted in delays and inadequate care, affecting the residents' ability to maintain their highest practicable physical, mental, and psychosocial well-being. Interviews and observations revealed that the facility's staffing levels were insufficient to meet the residents' needs. The Director of Nursing (DON) acknowledged that nurses and CNAs expressed concerns about the lack of support from other staff, such as home keepers and activity staff, who were unsure of their roles in assisting with resident care. The Lead CNA (LCNA) and other staff members reported challenges in providing timely care, including delays in showers, toileting, and turning schedules, which could impact residents' health, such as pressure ulcers. Specific resident cases illustrate the impact of these deficiencies. One resident expressed discomfort with male caregivers, yet was still assisted by them, causing distress. Another resident reported being unable to get out of bed until late in the day, missing activities and social interactions. Several residents complained about the infrequency of showers and the inability to choose their preferred bathing method. Additionally, residents experienced long wait times for assistance, leading to missed meals and unmet personal care needs. The facility's failure to provide adequate staffing and support for ADLs resulted in significant negative outcomes for the residents involved.
Failure to Remove Alleged Perpetrators During Abuse Investigations
Penalty
Summary
The facility failed to protect residents in response to allegations of abuse, specifically by not immediately removing the alleged perpetrators from resident care during active abuse investigations. In one case, a licensed nurse (LN) was accused of physically abusing a resident by hitting them on the head after a delay in responding to their call for assistance. Despite the resident's report of the incident to a supervisor, the LN continued to work their shift and was scheduled to work the following day, indicating a failure to adhere to the facility's policy of removing staff during abuse investigations. In another incident, a certified nurse assistant (CNA) was reported to have thrown a nightshirt at a resident's face with force, causing distress. Although the facility's investigation concluded that the CNA would no longer work in the resident's cottage, the CNA returned to work in the same area due to staffing shortages, causing the resident to feel unsafe and remain in their room all day. This action contradicted the facility's corrective action plan and further exposed the resident to potential harm. The facility's policy on abuse prohibition and prevention mandates immediate protection of residents from physical and psychological harm during investigations, including staff removal and increased supervision. However, the facility's failure to implement these measures in both cases placed residents at risk and demonstrated a lack of adherence to established protocols for handling abuse allegations.
Lack of Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis from June 21, 2024, to July 15, 2024. During this period, the DON was not present full-time, working only limited hours in the early morning and sometimes returning in the afternoon or working weekends as needed. The facility's administrator confirmed that the DON's last full-time day was June 21, 2024, and a new DON was not scheduled to start until July 29, 2024. This lack of full-time oversight by a DON placed all residents, with a census of 93, at substantial risk for subquality care. Interviews revealed that the DON was the only person designated for the role and was available through messaging and phone calls when not physically present. The facility's administrator stated that the Quality Director was designated as the interim DON after the previous DON's last day on July 15, 2024. The Quality Director worked full-time at the facility, Monday through Friday. The facility's job description for the Director of Nursing outlined responsibilities for administrative direction and clinical leadership, which were not fully met during the period in question.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
