Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Valdez Medical Center during CMS and state inspections, most recent first.
The facility failed to keep an employee’s State of Alaska background check clearance valid while the employee continued working with resident contact. Assistant #3 helped prep and cook resident meals and served lunch and dinner to LTC residents, including hand-delivering trays to residents in their rooms, while the renewed background check was still pending after the prior clearance expired. Payroll records showed the employee worked 164.38 hours without valid clearance, despite state notices that a new background check was needed and facility policies requiring screening and renewal.
A facility failed to timely report an allegation of verbal intimidation/harassment involving inappropriate sexual comments made by a CNA to a resident, and its abuse policy did not align with CFR reporting requirements. The resident had Alzheimer’s disease with behavioral disturbance, anxiety, and decreased functional mobility, required extensive assistance with personal care, and could not participate in an interview. Staff documented that the CNA made sexually explicit remarks during care, but leadership did not report the allegation to the State Survey Agency within the required timeframe and initially treated it as a disturbing conversation rather than abuse.
The facility failed to clearly designate one RN as the full-time DON for the LTC unit. Records, interviews, and observation showed conflicting roles for the DCS, LTC Manager, and a newly hired DON, with the DCS still performing DON and LTC Manager duties while payroll and HR records identified her as DCS and the new DON was at times coded as Acute RN instead of LTC DON. Facility documents, committee lists, badges, and job descriptions all reflected inconsistent leadership assignments.
Failure to document resident/rep acceptance or refusal of psychotropic meds. Three residents with dementia, depression, or behavioral symptoms were receiving psychotropic meds such as duloxetine, hydroxyzine, quetiapine, sertraline, trazodone, and memantine. The records showed risks and benefits were discussed with family members or POAs, but there was no documentation that the resident or surrogate accepted or declined the meds, and the DCS could not locate any notes showing consent.
The facility failed to complete required quarterly MDS reviews for two residents. One resident had vascular dementia with behavioral disturbance, depression, dysphasia, dehydration, and a history of falls, and the other had dementia, a ruptured aneurysm with subarachnoid hemorrhage, cardiomyopathy, CHF, and chronic hip pain after a total hip replacement. Both residents’ most recent MDSs were annual reviews, and the quarterly assessments were overdue beyond the 92-day timeframe. The DCS confirmed the quarterly assessments were due but not completed.
Physicians did not consistently conduct in-person assessments of residents at least every 60 days, with several residents experiencing extended gaps between visits. The facility lacked a reliable system for tracking and following up on missed appointments, and staff interviews confirmed that reminders were inconsistently communicated, leading to missed visits.
The Medical Director did not ensure physician compliance with required resident visits, resulting in multiple residents experiencing significant gaps between physician visits, some exceeding a year. The MD relied on staff to track visits and did not address the issue in QAPI meetings, leading to a lack of oversight and coordination of medical care.
Surveyors found that two residents received medications with incorrect labeling that did not match physician orders, including improper dosing instructions for Glipizide and Famotidine. Additionally, a bottle of Vitamin D was observed without an expiration date, which staff attributed to label damage from hand sanitizer use. These issues were confirmed by nursing staff and were not in compliance with facility policy requiring clear and accurate medication labeling.
The facility did not document that residents or their representatives received education on the benefits and potential side effects of Influenza and Pneumococcal vaccines before consent or declination. Although staff and public health partners may have provided education, there was no evidence of this in the medical records for several residents who received or declined immunizations.
The facility did not document that residents or their representatives were educated about the benefits and side effects of the COVID-19 vaccine before vaccination was offered or administered. For four residents, there was no evidence in the medical record that this required education occurred, despite facility policy requiring such documentation.
A resident with dementia and limited mobility was left exposed during and after a shower while receiving medication and personal care from staff, including a nurse and two CNAs. The resident was not adequately covered during transfers and care activities, contrary to facility policy and expectations for maintaining dignity and privacy.
A resident with a known pineapple allergy was served and consumed a meal containing pineapple after staff failed to recognize the allergen in a new sweet and sour sauce. The kitchen manager, relying on the KARDEX system for allergy information, was unaware that the new menu item contained pineapple, resulting in the resident being exposed to an identified allergen.
The facility did not maintain records of daily nurse staffing information for the required 18 months. While current staffing data was posted, there was no retention of previous records, and the LTC manager confirmed that the facility was unaware of the requirement to keep this information.
Failure to Maintain Valid Background Check Clearance for Employee with Resident Contact
Penalty
Summary
The facility failed to implement its abuse prevention screening process when it allowed Assistant #3 to continue working with resident contact after the individual’s State of Alaska background check clearance had expired. The report states that Assistant #3 had an Eligible Determination that was valid from one date to another, but emails from the State of Alaska Background Check Unit notified the facility that a new background check was needed by a specified date. A new background check application was not started until the day after the clearance expired, and the application status showed Assistant #3 was provisionally hired while the new check was pending. Payroll records showed Assistant #3 worked 164.38 hours during the period without valid background check clearance. During an interview, Assistant #3 stated that he/she helped prep and cook resident meals and served lunch and dinner in person to LTC residents on the unit. Observations showed kitchen staff bringing meals to residents in the dining room and hand delivering trays to residents in their rooms, including one resident observed receiving lunch in his/her room. The facility’s policies stated that staff would be screened for abuse records prior to hiring and that caregivers in Alaska must have their background checks renewed with the State of Alaska.
Failure to Timely Report Alleged Sexual Harassment and Policy Misalignment
Penalty
Summary
The facility failed to report an allegation of verbal intimidation/harassment involving inappropriate sexual comments made by a CNA to a resident immediately, or no later than 2 hours after the allegation was made or reported. The resident involved had diagnoses including Alzheimer’s disease with behavioral disturbance, decreased functional mobility, and anxiety, and required a two-person assist with brief changes every 2 to 3 hours and staff assistance with personal hygiene. An occupational therapy assessment also noted the resident was not able to follow simple commands or participate in an interview and became agitated when removed from the group setting, with staff concerns that a past history of trauma affected care during ADLs. An internal staff incident report documented that a nurse was told by another CNA that, while changing the resident, the CNA stared at the resident and made sexually explicit remarks during care, including an implied sexual proposition and a personal statement about sexual activity. The occurrence report categorized the event as workplace violence for verbal intimidation/harassment/bullying and identified the type as unwanted sexual comments/gestures. The facility’s initial report to the State Survey Agency was received two days after leadership was notified of the allegation, and the report documented that the incident was initially considered not abuse and was being reported as a disturbing conversation under investigation. The facility’s abuse policy defined abuse to include intimidation and stated that sexual abuse includes sexual harassment, but the policy language focused on reporting only abuse that resulted in serious bodily injury within the 2-hour timeframe. During interview, the CAO stated she did not initially interpret the comments as harassment, but later acknowledged they could be interpreted that way, and said she tried to investigate before sending the initial report. The policy did not align with the regulatory requirement to report allegations of abuse, neglect, exploitation, or mistreatment immediately, but no later than 2 hours after the allegation was made.
Unclear designation of full-time DON
Penalty
Summary
The facility failed to clearly designate one RN to serve as the full-time Director of Nursing for the LTC unit. Record review, staff interviews, and observation showed conflicting leadership roles for the Director of Clinical Services (DCS), the LTC Manager, and a newly hired DON, and the facility could not demonstrate that one RN was consistently assigned to provide LTC nursing leadership and oversight. Facility documents identified the DCS in different ways. The Key Contacts list identified the DCS as the LTC DON, RN/MDS, while the LTC Contact Resources list identified her as the LTC Manager. During interview, an LN stated the DCS was the LTC Manager and had always been the LTC Manager, and that another person would soon transition into the DON role. Observation showed the DCS wore a badge identifying her as Manager Long Term Care, while her office door title and business card identified her as Director of Clinical Services. The LTC Quality Committee list showed the DCS attending in the DCS role, while another staff member attended as the RN LTC DON. HR, payroll, and job description records also showed conflicting role assignments. The DCS was designated in HR as DCS effective 4/6/26, but the CAO stated she continued performing DON duties because the newly hired DON was still transitioning and had not fully assumed responsibilities. The DCS stated she was officially in payroll as DCS but was still doing DON and LTC Manager work, and the CAO acknowledged there was no documentation separating hours or duties between the DON and DCS roles. The DCS's offer letter stated she would assume the DCS role effective 4/6/26, while the newly hired DON's offer letter stated he would assume the DON role effective 4/5/26. Payroll records showed the DCS worked 40 hours per week with no time specifically designated to the LTC DON role, and the new DON's payroll was coded as Acute RN on several dates rather than LTC DON. The DCS's annual evaluation still reflected her LTC Manager role, and the job descriptions described separate responsibilities for DCS, LTC Manager RN, and Director LTC RN.
Failure to Document Acceptance or Refusal of Psychotropic Medications
Penalty
Summary
The facility failed to document that residents or their representatives were informed in advance and were able to accept or decline the initiation or continued use of psychotropic medications after receiving information about the risks, benefits, and alternatives. This deficiency was identified for 3 residents reviewed for unnecessary medications, specifically Residents #2, #6, and #9, and was cited as a violation of the residents’ right to participate in treatment decisions. Resident #2 had diagnoses including vascular dementia with mood disturbance, Alzheimer’s disease, and depression. The MAR showed use of multiple psychotropic medications, including duloxetine 30 mg and 60 mg daily, hydroxyzine 25 mg nightly, quetiapine 37.5 mg in the morning and 25 mg in the afternoon, and memantine 10 mg twice daily. The record contained psychotropic risk/benefit consent forms for duloxetine, memantine, hydroxyzine, and quetiapine, but the forms documented only that risks and benefits were discussed with the family member or POA and that no additional information was requested; there was no documentation that the family accepted or declined the medications. Resident #6 had diagnoses including vascular dementia and depression and was receiving sertraline 100 mg daily. The psychotropic risk/benefit consent form documented that risks and benefits were discussed with the family member and that no additional information was requested, but it did not document acceptance or refusal of the medication. Resident #9 had diagnoses including Alzheimer’s disease with behavioral disturbance and agitation due to dementia and was receiving hydroxyzine 12.5 mg daily, hydroxyzine 25 mg nightly, sertraline 75 mg daily, and trazodone 25 mg nightly. The consent form for these psychotropic medications likewise documented discussion of risks and benefits with a family member, but no documentation showed that the family accepted or declined the initiation or continued use of the medications. During interview, the DCS stated consent was documented using either the paper form or electronic note, but she could not locate notes showing acceptance or refusal for these residents and stated the forms did not contain language showing the families or POAs accepted or refused the psychotropic medications.
Missed Quarterly MDS Reviews for Two Residents
Penalty
Summary
The facility failed to ensure quarterly MDS review requirements were completed for 2 residents, Resident #6 and Resident #7, out of 5 residents reviewed. Record review showed Resident #6 was admitted with diagnoses including vascular dementia with behavioral disturbance, depression, dysphasia, dehydration, and a history of falls. The most recent MDS for Resident #6 was dated 11/29/25 and was an annual review, with the facility 75 days past the 92-day timeline for the next quarterly review assessment. Resident #7 was admitted with diagnoses including dementia, subarachnoid hemorrhage due to ruptured aneurysm, cardiomyopathy, congestive heart failure, and chronic hip pain after a total left hip replacement. The most recent MDS for Resident #7 was dated 11/26/25 and was an annual review, with the facility 78 days past the 92-day timeline for the next quarterly review assessment. During interview, the DCS stated the most current assessments for both residents were completed in 11/2025 and that their quarterly assessments were due in 2/2026, but were not completed. The facility policy stated quarterly assessments are to be completed no later than the ARD of the prior assessment plus 92 calendar days.
Failure to Ensure Timely In-Person Physician Visits
Penalty
Summary
The facility failed to ensure that physicians consistently conducted in-person assessments of residents at least once every 60 days, as required. Record review revealed multiple instances where residents experienced significant gaps between physician visits, ranging from 71 to 368 days. These lapses were documented for several residents, with some not being seen by a physician for over three months, and one resident not seen for over a year. The facility's own Physician Visits Non-compliance Flowsheets confirmed these extended intervals between required visits. Interviews with the Long-Term Care Manager and the Medical Director indicated that the facility lacked a reliable system for tracking and following up on missed physician appointments. Nurses maintained logs, but reminders to physicians were inconsistently communicated, and the process was further hindered when physicians were unavailable due to vacations or busy schedules. The Medical Director acknowledged reliance on staff for reminders and admitted to missing visits, especially during periods of absence or high workload. The facility's policy required timely physician visits and prompt rescheduling of missed appointments, but these procedures were not effectively implemented.
Failure of Medical Director to Oversee Physician Visit Compliance
Penalty
Summary
The facility failed to ensure that the Medical Director (MD) fulfilled her responsibilities for oversight and coordination of medical care, specifically regarding physician compliance with required resident visits. Review of facility documentation and policies confirmed that the MD was responsible for implementing resident care policies and coordinating medical care, including organizing and coordinating physician services. However, multiple instances were identified where residents did not receive physician visits within the required intervals, with gaps ranging from 71 to 368 days between visits, exceeding the policy requirement of at least one physician visit every 60 days after the first 90 days post-admission. Interviews revealed that the MD relied on staff to track physician visits and did not have a system in place to ensure compliance. The MD acknowledged a lack of oversight and expressed that the responsibility could not rest solely on her. Additionally, the Regional Quality Manager confirmed that the MD did not proactively address issues related to physician visit compliance in QAPI meetings and was unaware of the extent of noncompliance until informed during the survey. These actions and inactions resulted in a failure to provide adequate oversight and coordination of medical care as required by facility policy.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were labeled in accordance with physician orders and did not always include expiration dates. For one resident, a pack of Glipizide 10 mg tablets was labeled to be administered three times daily with meals, while both the medication administration record and the physician's order specified the medication should be given two times daily before meals. A licensed nurse confirmed that the label should have been updated by the pharmacy to reflect the correct dosing instructions. In another instance, a pack of Famotidine 20 mg was labeled for evening administration, but the evening dose was on hold per the medication administration record, and there was no physician order for a morning dose. The label had a handwritten time added, and the nurse acknowledged the label should have been changed to match the current order. Additionally, an observation revealed a bottle of Cholecalciferol (Vitamin D) 5,000 units without an expiration date. A nurse explained that the expiration date had been erased due to the use of alcohol-based hand sanitizer during medication preparation, and that nurses typically check expiration dates monthly. The facility's policy requires all medication containers to be clearly labeled, including directions for use and expiration dates, to ensure safe and effective patient care.
Lack of Documentation for Vaccine Education Prior to Consent or Declination
Penalty
Summary
The facility failed to ensure that documentation was present in the medical records showing that residents or their representatives were educated about the benefits and potential side effects of Influenza and Pneumococcal immunizations prior to obtaining consent or declination for vaccine administration. Record review revealed that several residents received these immunizations, and one resident declined, but there was no documentation in the electronic health records indicating that education was provided before the vaccines were offered. The facility's vaccination policy stated that education would be provided to all residents and their legal representatives regarding vaccination risks and benefits, but this was not reflected in the records reviewed. Interviews with facility staff confirmed that while education may have been provided verbally, it was not documented in the residents' records. The Long-Term Care Manager indicated that the State of Alaska Public Health provided education at the time of vaccination, but relied on the vaccination record as evidence of education, which did not specifically document the educational content or its delivery. The Clinical Director also acknowledged that staff were providing education but not documenting it. This lack of documentation affected all residents reviewed and had the potential to affect all residents in the facility.
Lack of Documentation of COVID-19 Vaccine Education
Penalty
Summary
The facility failed to ensure that documentation was present in the medical records to show that residents or their representatives were educated about the benefits and potential side effects of the COVID-19 vaccine prior to either consenting to or declining vaccination. Specifically, for four out of five residents reviewed, there was no evidence in the electronic health record that education was provided before the vaccine was offered or administered. This included residents who received the vaccine as well as one resident whose representative declined the vaccine on their behalf. Interviews with facility staff revealed that while education may have been provided verbally by staff or by the State of Alaska Public Health prior to vaccination, this education was not documented in the residents' records. The facility's own policy required that education regarding vaccination risks and benefits be provided to all residents and their legal representatives, but there was no documentation to confirm this occurred for the affected residents.
Failure to Maintain Resident Dignity and Privacy During Care Activities
Penalty
Summary
A deficiency occurred when a resident with dementia, muscle weakness, impaired ability to follow directions, and decreased mobility was not provided care in a manner that promoted dignity and respect. During a medication administration, the resident was observed seated naked in a shower chair with only a towel on their back and a wet Hoyer sling underneath. Two CNAs were present in the room, and a licensed nurse entered to administer medication while the resident remained exposed. Following this, the CNAs transferred the resident to bed using a mechanical lift, during which the resident's anterior body remained exposed. The CNAs then performed personal care and dressed the resident. Interviews with the CNAs and the Clinical Director confirmed that the expectation was to provide privacy and cover the resident after a shower, especially during transfers and care activities. The facility's policy and the resident's bill of rights emphasized the importance of promoting dignity and personal privacy during care. However, the resident was not adequately covered during these activities, and the Clinical Director acknowledged that the resident should have been covered, particularly during medication administration and in the presence of both male and female staff.
Resident Served Allergen Due to Ingredient Oversight
Penalty
Summary
The facility failed to ensure that a resident with a documented pineapple allergy received a diet free from this allergen. On the day in question, the resident consumed a sweet and sour sauce that contained pineapple, as confirmed by both the resident and a licensed nurse. The kitchen manager stated that while the facility uses a KARDEX system to track resident allergies and checks it before plating meals, the new menu item was not recognized as containing pineapple. Review of the ingredient list for the sweet and sour sauce confirmed the presence of pineapple, and the resident's KARDEX clearly listed pineapple as an allergy. The facility's policy requires accommodation of resident allergies, intolerances, and preferences.
Failure to Retain Nurse Staffing Records for Required Period
Penalty
Summary
The facility failed to maintain records of daily nurse staffing information for the required 18-month period. During an observation, it was noted that while the current day's staffing information was posted, there was no documentation or retention of previously posted staffing data. In an interview, the Long-Term Care Manager confirmed that the facility did not take daily photographs of the staffing board or otherwise retain the required records, stating they were unaware of the requirement. This deficiency affected all residents in the facility, as well as visitors' ability to review historical staffing levels.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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