Citations in Alaska
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Alaska.
Statistics for Alaska (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Alaska
Surveyors found expired and/or opened medications and medical supplies on multiple medication and treatment carts, including items with illegible expiration dates. Staff confirmed these items should have been discarded. Additionally, emergency medications were stored in a refrigerator with temperatures above the recommended range, and temperature logs showed inconsistent monitoring and documentation.
A resident with multiple diagnoses, including diabetes and neuropathy, had a wound on the left shin that was reclassified from diabetic to vascular in wound care notes. However, the most recent MDS assessment did not reflect the presence of a venous or arterial ulcer, as required. The facility had relied on a contracted wound care provider for wound classification and later identified issues with incorrect wound categorization.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
Two residents did not receive care in accordance with professional standards and their care plans when staff failed to notify the physician and document interventions after significant changes in condition, including a leaking G-Tube and acute hypotension with altered mental status. Improvised repairs and lack of timely escalation led to missed care and increased risk for complications.
A resident with multiple chronic conditions continued to receive Santyl ointment for wound care after the medication was discontinued in the updated care plan. Staff administered the ointment thirteen times following the change, and observation confirmed ongoing use despite the revised orders. The Resident Care Manager acknowledged that Santyl should have been stopped according to the new wound care instructions.
A resident with multiple neurological and mental health diagnoses reported concerns about staff using profanities and inappropriate names. The allegation was disclosed during an IDT meeting attended by the Administrator, DON, and Resident Advocate, but no formal investigation was conducted and the incident was not reported to the State Survey Agency within the required timeframe, contrary to facility policy.
A resident with multiple neurological and mental health diagnoses reported being verbally abused by a nurse, including the use of profanities and derogatory language. The facility did not conduct a formal investigation, failed to report the incident to the State Survey Agency, and allowed the alleged staff member to continue working in the resident's unit, contrary to facility policy.
The facility's assessment contained inaccurate information regarding bed capacity and physical layout, with documentation stating a higher licensed capacity and a different building structure than what was confirmed by state licensing records and staff interview.
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 resident with significant medical needs was admitted to the facility and, despite having personal belongings available, their room remained unpersonalized for over a month, with items left in boxes and minimal personal effects displayed. Staff did not contact the family or representative to assist with unpacking or personalizing the room, contrary to facility policy, resulting in the resident being denied a homelike environment.
Expired Medications and Improper Storage Temperatures Identified
Penalty
Summary
Surveyors observed that the facility failed to properly store and label medications and medical supplies. Specifically, expired and/or opened medications and supplies were found on multiple medication and treatment carts, including hypodermic safety needles, Diclofenac Sodium Topical Gel, IV start kits, C-Pantoprazole suspension, Aspirin tablets with an illegible expiration date, Nitroglycerin tablets, glucose gels, wound care products, and COVID-19 antigen test kits. Staff interviews confirmed that these items were expired or opened and should have been discarded, and that faded expiration dates made it impossible to determine if some medications were still safe for use. Additionally, the facility failed to maintain emergency medications under safe temperature control. Review of the medication refrigerator temperature logs revealed numerous instances where temperatures were not documented, as well as several recorded temperatures above the recommended range of 36-46°F. On the day of observation, the refrigerator was found to be operating at 48°F and 51°F, and emergency medication kits containing various critical drugs were stored inside. Staff confirmed that temperature checks were not consistently performed and that out-of-range temperatures were not reported as required. Facility policy and FDA recommendations both require proper storage and temperature monitoring for these medications.
Failure to Accurately Code MDS for Vascular Wound
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded for a resident with a vascular wound. Record review showed that the resident was admitted with multiple diagnoses, including dementia, CVA with left-sided hemiparesis, obesity, chronic pain, diabetes mellitus type II, and neuropathy. Wound care notes initially described a wound on the left shin as a diabetic wound, but subsequent documentation reclassified it as a vascular wound. Despite this, the most recent MDS assessment did not code for venous or arterial ulcers under section M1030, even though the look-back period included the time when the wound was documented as vascular. Further review of the Resident Assessment Instrument (RAI) User's Manual confirmed that the presence of venous and arterial ulcers should be documented and used to inform the resident's care plan. During an interview, the Resident Care Manager stated that the facility had previously relied on a contracted wound care provider for wound classification and had discovered issues with incorrect classification of wounds. This led to the use of a different provider for more accurate wound identification. The failure to accurately code the MDS assessment for the resident's vascular wound constituted a deficiency in ensuring accurate assessment and documentation.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Notify Physician and Provide Standard Care for Changes in Condition
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice and resident care plans for two residents. For one resident with a gastrostomy tube (G-Tube), the nurse observed a leak around the tube and improvised a repair using rubber bands and masking tape instead of medical-grade equipment. The nurse did not notify the on-call provider or document the incident at the time, resulting in the resident being off tube feeds for several hours. The makeshift repair led to soiling and discoloration at the G-Tube site, with stagnate content present, increasing the risk for infection. Facility policy and adopted clinical procedures required immediate provider notification and proper documentation for such complications, which was not followed. Another resident with a history of heart failure, coronary angioplasty, and atrial fibrillation experienced a significant decline in condition, including acute hypotension, refusal of medications, food, and fluids, and altered mental status. The nurse documented the low blood pressure and change in mentation but did not notify the physician or document any provider notification. The resident's care plan specifically required monitoring for changes in cognitive status and prompt physician notification for observed changes or side effects of medication, including hypotension. Facility policy also mandated immediate physician notification and documentation for significant changes in condition or refusal of treatment, which was not done in this case. These failures to escalate care, notify the physician, and document interventions as required by facility policy and professional standards resulted in the residents not receiving timely and appropriate treatment and care. The deficiencies were identified through record review and staff interviews, with evidence showing that the required actions were not taken at the time of the incidents.
Failure to Discontinue Medication After Change in Wound Care Orders
Penalty
Summary
A deficiency occurred when the facility failed to discontinue a medication order after a change in wound care orders for one resident. The resident, who had multiple diagnoses including dementia, CVA with left-sided hemiparesis, obesity, chronic pain, diabetes mellitus type II, and neuropathy, was initially prescribed Santyl ointment for sacral wound care. The physician's order for Santyl was replaced with a new wound care regimen that no longer included Santyl. Despite this change, the facility continued to administer Santyl ointment for thirteen documented instances after the new order was in effect. Observation confirmed that a licensed nurse applied Santyl to the resident's sacral wound area even after the medication was discontinued in the updated care plan. Interview with the Resident Care Manager confirmed that the Santyl should have been discontinued following the revised wound care order. This failure resulted in the resident receiving unnecessary medication administrations that were not aligned with the current physician's orders.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to immediately report an allegation of verbal abuse to the State Survey Agency as required by federal regulations. During an IDT care conference, a resident with diagnoses including Parkinson's disease, anxiety disorder, PTSD, and depression expressed concerns about the use of profanities and inappropriate names by a staff member. When questioned further, the resident identified the staff member involved. Despite this disclosure, no formal investigation was conducted, and the incident was not reported to the State Survey Agency within the required two-hour timeframe. Interviews confirmed that the Administrator, DON, and Resident Advocate were present during the meeting when the allegation was made and were aware of the resident's concerns. The facility's own abuse policy mandates immediate reporting of all abuse allegations, but this protocol was not followed. The failure to report the alleged verbal abuse promptly had the potential to place vulnerable residents at risk.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to respond appropriately to an allegation of verbal abuse involving one resident with a history of Parkinson's disease, anxiety disorder, PTSD, and depression. The resident and their representative reported that a licensed nurse used profanities and derogatory language towards the resident on multiple occasions. The resident expressed unhappiness and fear of retaliation, and the concern was also documented during an IDT care conference. Despite these allegations, the facility did not conduct a thorough or formal investigation, nor did they document any inquiry into the matter. The incident was not reported to the State Survey Agency as required, and there was no evidence that the facility followed its own abuse policy regarding investigation and reporting. Additionally, the alleged staff member continued to work scheduled shifts, including in the unit where the resident resided, while the allegations were unresolved. The facility's abuse policy mandates immediate reporting, investigation, and removal of the alleged perpetrator from resident contact until the investigation is complete. However, these steps were not taken, and there was no documentation of witness interviews or notification to the resident's family or legal representative. The lack of action left the resident at risk of continued abuse and contributed to their distress.
Inaccurate Facility Assessment Documentation
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was up to date and accurate, as required. Record review revealed discrepancies in the reported bed capacity and facility description. The facility assessment stated a licensed capacity of 96 residents, while the State of Alaska license indicated the facility was licensed for 50 beds. During an interview, the Director of Community Liaison confirmed the correct bed capacity was 50 beds, highlighting the inaccuracy in the assessment documentation. Additionally, the facility assessment described the physical layout as consisting of 8 cottages, 8 courtyards, and a common building, whereas the initial licensing application described the facility as a single building with two wings, each containing specific hallway and room arrangements. These inconsistencies demonstrate that the facility assessment did not accurately reflect the facility's current resources and structure, as required for both day-to-day operations and emergency preparedness.
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 Provide Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a homelike environment was established and maintained for a resident who had been admitted over a month prior. Despite the resident's history of having a personalized room at a previous facility, observations revealed that the resident's personal belongings remained packed in boxes, with minimal personal items displayed in the room. The only visible personal effects were a few pictures on a corkboard, which was obscured behind a television and not easily visible from the resident's bed. The room otherwise lacked any personal touches or homelike features. Interviews with facility staff indicated that it was the responsibility of the assigned CNA to inventory and put away personal items upon admission, and that family members were typically contacted to assist with unpacking. However, there was no documentation that staff had reached out to the family or the resident's representative for assistance, nor was there any record of resistance from the resident or representative regarding the personalization of the room. The facility's policy required social services to contact family or responsible parties to help personalize the resident's environment, but this was not done, resulting in the resident being denied a homelike environment.
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