Deficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
67% worse than Alaska average
Alaska average: 7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jul 3, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and overall facility operations.
Findings
The facility was found deficient in several areas including failure to implement fall prevention interventions for a resident, medication administration errors involving incorrect route of administration, and inadequate infection prevention and control practices such as failure to use required personal protective equipment and maintain a clean wound care environment. All deficiencies were assessed as causing minimal harm or potential for actual harm affecting a few residents.
Deficiencies (3)
Failed to implement fall prevention interventions for Resident #49, including improper use of non-skid socks.
Failed to administer medication via the ordered route for Resident #34, resulting in a medication error.
Failed to ensure infection control procedures were properly implemented for Residents #4, #54, and #58, including failure to use gowns and maintain a clean wound care environment.
Report Facts
Residents sampled: 16
Residents affected: 1
Residents affected: 1
Residents affected: 3
Urine output: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Failed to correct Resident #49's non-skid socks and did not wear gown during catheter care |
| LN #1 | Licensed Nurse | Prepared medication and administered oral medication instead of via PEG tube for Resident #34 |
| CNA #4 | Certified Nursing Assistant | Failed to wear gown during care of Resident #54 and did not perform hand hygiene between glove changes |
| Student #1 | Assisted CNA #4 during care of Resident #54 without wearing gown | |
| LN #3 | Licensed Nurse | Failed to maintain clean wound care environment for Resident #58 |
| Director of Nursing | Director of Nursing | Provided interviews regarding medication administration and infection control policies |
| Nursing Supervisor #2 | Nursing Supervisor | Provided interview regarding fall prevention care plan adherence |
| Infection Preventionist | Infection Preventionist | Provided interview regarding Enhanced Barrier Precautions |
Inspection Report
Routine
Census: 53
Deficiencies: 14
Date: Jun 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, care planning, medication management, safety, and facility operations.
Findings
The facility had multiple deficiencies including failure to ensure informed consent for psychotropic medications, incomplete admission and significant change assessments, inadequate care planning for smoking and fall prevention, incomplete neurological assessments after falls, expired CPR certifications for staff, and compromised kitchen freezer door gasket posing food safety risks.
Deficiencies (14)
Psychotropic Medication Informed Consent forms were not completed accurately, timely, or with original signatures for multiple residents.
Facility failed to send timely transfer/discharge notifications to the State Long Term Care Ombudsman for some residents.
Comprehensive admission assessment using MDS was not completed timely for one resident.
Significant change reassessment was not completed within 14 days after dementia diagnosis for one resident.
Care plans failed to address smoking risks and lacked specific interventions for smoking residents.
Care plans were not revised to reflect changing needs for level of support during appointments, fall prevention interventions, and behavioral management.
Two nursing staff worked with expired CPR certifications.
Range of motion exercises were not documented or consistently provided for one resident with quadriplegia.
Neurological assessments after unwitnessed falls were incomplete or inaccurately documented for one resident.
Smoking assessments and safe storage of smoking paraphernalia were not conducted for residents who smoked.
Physician Orders for Life-Sustaining Treatment (POLST) forms were completed using photocopied signatures and lacked documented provider review.
Medication consent forms for psychotropic drugs contained photocopied signatures and lacked proper consent documentation.
Morphine PRN medication order had a dose range without parameters, leading to frequent maximum dosing without clear guidance.
Kitchen walk-in freezer door gasket was damaged, causing water leakage and potential food safety hazard.
Report Facts
Residents on psychotropic medications: 25
Residents reviewed for CPR certification: 15
Resident falls: 28
Days worked without valid CPR: 17
Days worked without valid CPR: 7
Residents sampled: 14
Residents unsampled: 39
Puddle size: 18
Puddle size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Director | Medical Director | Approved photocopied signatures on blank consent and POLST forms |
| Physician #22 | Physician | Photocopied signature on multiple consent and POLST forms |
| Physician #5 | Physician | Photocopied signature on multiple consent forms |
| Licensed Nurse #33 | Licensed Nurse | Used blank consent and POLST forms with photocopied signatures during admissions |
| Director of Nursing | Director of Nursing | Interviewed about deficiencies in consent forms, care planning, smoking assessments, and neurological assessments |
| Certified Nursing Assistant #1 | CNA | Observed repositioning Resident #6 with 1-person assist despite care plan requiring 2-person assist |
| Certified Nursing Assistant #2 | CNA | Assisted with transfer of Resident #6 |
| Licensed Nurse #6 | Licensed Nurse | Manually updated report sheet to indicate 2-person assist for Resident #6 |
| Pharmacist #20 | Pharmacist | Discussed morphine dose range order and hospice medication management |
| Physician #11 | Physician | Discussed fall prevention and behavioral interventions for Resident #18 |
| Certified Nursing Assistant Coordinator | CNA Coordinator | Described CNA workflow and transfer procedures |
| Dietary Staff #4 | Dietary Staff | Notified maintenance about freezer door gasket and water on floor |
| Dietary Staff #19 | Dietary Staff | Reported maintenance request for freezer door gasket |
| Human Resources Director | HR Director | Interviewed about expired CPR certifications and training policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 6, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure that the resident representative consented to psychotropic medication dosage changes before administration.
Complaint Details
The complaint investigation found that the facility did not have a Psychotropic Medication Consent policy and failed to obtain consent for multiple dosage changes of Risperidone for Resident #4. The resident representative disagreed with dosage increases that were made without prior consent. The Psychiatric Advanced Nurse Practitioner was instructed to complete consent forms for all future dosage changes starting 7/6/23.
Findings
The facility failed to obtain consent from the resident representative for multiple dosage changes of Risperidone for Resident #4, placing the resident at risk of unnecessary medication and adverse effects. Interviews and record reviews confirmed missing consents for several dosage changes and lack of a formal psychotropic medication consent policy.
Deficiencies (1)
Failure to ensure resident representative consented to psychotropic medication dosage changes before administration.
Report Facts
Residents reviewed for psychotropic medications: 4
Residents affected: 1
Dates of medication orders: 12
Consent form dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Psychiatric Advanced Nurse Practitioner | PANP | Named in relation to responsibility for completing psychotropic medication consent forms and interview about medication dosage changes |
| Director of Nursing | DON | Stated the requirement for psychotropic medication consent for dosage changes and instructed PANP to complete consent forms |
| Resident Representative | Interviewed regarding consent and disagreement with medication dosage increases | |
| Administrator | Interviewed about facility policy on psychotropic medication consent |
Inspection Report
Routine
Deficiencies: 17
Date: Mar 24, 2023
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, resident rights, care planning, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, incomplete assessments for self-administration of medications, unresolved resident grievances, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, unsafe food storage practices, failure to maintain emergency equipment and freezer temperature logs, improper medication reconciliation, and failure to ensure valid background checks for employees.
Deficiencies (17)
Failed to obtain informed consent for psychotropic medications for one resident.
Failed to assess safety prior to self-administration of medications for five residents.
Failed to honor resident rights to self-determination by not providing a method to store perishable food brought by family or visitors.
Failed to resolve a grievance for a resident regarding missing money and did not provide a written grievance decision.
Failed to ensure accurate Minimum Data Set (MDS) assessments including discharge assessments, hearing aids, oxygen therapy, and denture status.
Failed to develop and implement individualized care plans meeting residents' medical and psychosocial needs.
Failed to ensure wanderguard tag device was checked weekly as per manufacturer's instructions.
Failed to assess timely discontinuation of Foley catheter for one resident.
Failed to ensure head of bed elevation of at least 30 degrees during enteral feedings for one resident.
Failed to provide safe and appropriate respiratory care including lack of physician orders for oxygen and CPAP cleaning, and incomplete care plans for three residents.
Failed to ensure accurate reconciliation of liquid narcotic medication due to lack of calibration on medication bottle.
Failed to ensure clear guidance and sequencing for use of as needed bowel medications for one resident.
Failed to ensure medications were labeled in accordance with professional principles; a discharged resident's medication was used as stock without proper relabeling.
Failed to ensure menus met nutritional needs and were accurate for two residents receiving low sodium diets.
Failed to store food under proper sanitation and food handling practices in the central kitchen, including unlabeled opened containers, cross contamination risks, and lack of temperature monitoring in unit freezer.
Failed to ensure valid criminal background checks for four employees who continued to work pending variance approval.
Failed to ensure daily maintenance checks on two emergency code carts and failed to maintain temperature logs and monitoring for a unit freezer.
Report Facts
Residents sampled: 16
Residents affected: 5
Residents affected: 1
Residents affected: 1
Employees: 4
Days worked: 21
Hours worked: 241.75
Days worked: 24
Hours worked: 193.75
Days worked: 40
Hours worked: 305.25
Days worked: 36
Hours worked: 229.15
Code cart checks: 14
Code cart checks: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Worked 241 hours after background check ineligibility notification |
| NH #1 | Neighborhood Helper | Worked 193 hours after background check ineligibility notification |
| [NAME] #2 | Cook | Worked 305 hours after background check ineligibility notification |
| Housekeeper #1 | Housekeeper | Worked 229 hours after background check ineligibility notification |
| Director of Nursing | Director of Nursing | Named in multiple findings including medication consent, care planning, and medication reconciliation |
| MDS Coordinator | MDS Coordinator | Named in findings related to MDS assessments and care plans |
| Pharmacist | Pharmacist | Named in medication reconciliation finding |
| Dietician | Dietician | Named in dietary menu accuracy finding |
| Kitchen Manager | Kitchen Manager | Named in food storage and sanitation findings |
| Human Resources Director | Human Resources Director | Named in background check findings |
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