Deficiencies (last 3 years)
Deficiencies (over 3 years)
22.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
224% worse than Alaska average
Alaska average: 7 deficiencies/yearDeficiencies per year
36
27
18
9
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
Annual Inspection
Deficiencies: 3
Date: Jul 3, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in several areas including failure to implement fall prevention interventions for a resident, medication administration errors related to route of administration, and inadequate infection prevention and control practices involving personal protective equipment and wound care.
Deficiencies (3)
Failed to implement fall prevention interventions for Resident #49, specifically not ensuring non-skid socks were worn correctly.
Failed to administer medication via the prescribed route for Resident #34, resulting in a medication error.
Failed to ensure proper infection control procedures, including use of personal protective equipment and maintaining a clean environment during wound care for Residents #4, #54, and #58.
Report Facts
Residents sampled: 16
Urine output: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and infection control practices |
| Nursing Supervisor #2 | Nursing Supervisor | Interviewed about staff expectations for following care plans and fall prevention |
| CNA #1 | Certified Nursing Assistant | Observed failing to correct Resident #49's non-skid socks and not wearing gown during catheter care |
| CNA #2 | Certified Nursing Assistant | Interviewed about fall prevention measures and care plan adherence |
| CNA #3 | Certified Nursing Assistant | Interviewed about training and use of care plans |
| CNA #4 | Certified Nursing Assistant | Observed not wearing gown during care of Resident #54 |
| Licensed Nurse #1 | Licensed Nurse | Observed administering medication incorrectly and catheter care |
| Licensed Nurse #3 | Licensed Nurse | Observed wound care with improper clean field setup |
| Infection Preventionist | Infection Preventionist | Interviewed about staff training and expectations for Enhanced Barrier Precautions |
Inspection Report
Routine
Census: 53
Deficiencies: 13
Date: Jun 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including informed consent for psychotropic medications, resident transfer notifications, admission assessments, care planning, medication management, and facility safety.
Findings
The facility failed to ensure psychotropic medication consents were accurately and timely completed with original signatures, failed to notify the Long Term Care Ombudsman of resident transfers, did not complete a comprehensive admission assessment for one resident, failed to complete timely reassessments after significant changes, did not develop or revise care plans adequately for smoking and behavioral needs, allowed staff to work without valid CPR certification, failed to provide range of motion exercises as ordered, did not complete neurological assessments after unwitnessed falls, failed to assess safe smoking practices, used photocopied signatures on POLST forms, and had unsafe kitchen equipment conditions.
Deficiencies (13)
Psychotropic Medication Informed Consent forms were not completed accurately, timely, or with original signatures for multiple residents.
Facility failed to notify the Long Term Care Ombudsman of resident transfers for some residents.
Comprehensive admission assessment using MDS was not completed timely for one resident.
Comprehensive reassessment after significant change in condition was not completed timely for one resident.
Care plans were not developed or revised to address smoking risks and behavioral interventions adequately for several residents.
Two nursing staff worked without valid CPR certification for multiple days.
Range of motion exercises were not documented or provided as ordered for one resident.
Neurological assessments after unwitnessed falls were incomplete or inaccurate for one resident.
Smoking assessments and safe storage of smoking paraphernalia were not conducted for residents who smoked.
POLST forms were completed using photocopied physician signatures on blank forms without documented provider review.
Medication consents for psychotropic drugs were incomplete or missing for multiple residents.
Medication dose range orders lacked parameters for administration, exposing residents to unnecessary medication doses.
Kitchen walk-in freezer door gasket was damaged causing water leakage and potential food safety risk.
Report Facts
Residents on psychotropic medications: 25
Residents reviewed for CPR certification: 15
Residents with falls: 28
Days worked without valid CPR: 17
Days worked without valid CPR: 7
Residents census: 53
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 | Confirmed use of photocopied signatures on consent forms during admissions |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding deficiencies and facility practices |
| Human Resources Director | Human Resources Director | Interviewed regarding CPR certification and training |
| Pharmacist #20 | Pharmacist | Interviewed about medication dose range orders |
| Physical Therapist #1 | Physical Therapist | Interviewed about restorative care and documentation |
| Physician #11 | Physician | Interviewed about behavioral interventions for Resident #18 |
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
Complaint Investigation
Deficiencies: 1
Date: Jul 6, 2023
Visit Reason
The inspection was conducted due to 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 revealed 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 stated disagreement with dosage increases that were made without consultation. The Psychiatric Advanced Nurse Practitioner was instructed to complete consent forms for dosage changes starting 7/6/23.
Findings
The facility failed to obtain proper consent from the resident representative for changes in psychotropic medication dosages for Resident #4, placing the resident at risk of unnecessary medication and adverse effects. Multiple medication dosage changes were made without documented consent, and the facility lacked a formal Psychotropic Medication Consent policy.
Deficiencies (1)
Failure to ensure resident representative consented to psychotropic medication dosage changes before administration.
Report Facts
Medication dosage changes without consent: 8
Consent forms signed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated there should have been Psychotropic Medication consent for every medication dosage change and instructed PANP to complete consent forms starting 7/6/23 |
| Psychiatric Advanced Nurse Practitioner | Psychiatric Advanced Nurse Practitioner | Responsible for completing Psychotropic Medication Risk and Benefits and Consent forms starting 7/6/23; provided statements about consent and dosage changes |
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 |
Inspection Report
Routine
Deficiencies: 16
Date: Mar 24, 2023
Visit Reason
The inspection was conducted as 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, improper medication reconciliation, inaccurate dietary orders, unsafe food storage practices, failure to maintain essential equipment, and noncompliance with state background check requirements for employees.
Deficiencies (16)
Failed to obtain informed consent for psychotropic medications for 1 resident.
Failed to assess 5 residents for safety prior to self-administration of medications.
Failed to resolve a grievance for 1 resident regarding missing money and did not provide a written grievance decision.
Failed to ensure MDS assessments accurately reflected residents' status including discharge assessment, hearing aids, oxygen therapy, and broken dentures.
Failed to develop and implement individualized care plans meeting residents' medical and psychosocial needs.
Failed to check wanderguard tag device battery weekly as recommended, only monthly checks were documented.
Failed to timely assess for discontinuation of foley catheter for 1 resident.
Failed to ensure resident's head of bed was elevated at least 30 degrees during enteral feedings.
Failed to ensure respiratory care was consistent with professional standards including lack of physician orders for oxygen and CPAP cleaning, and incomplete care plans.
Failed to ensure accurate reconciliation of liquid narcotic medication due to lack of calibration on medication bottle.
Failed to ensure duplicative constipation medications had clear guidance and sequence of use.
Failed to ensure medications were labeled properly; a discharged resident's melatonin blister pack was re-labeled as stock and used.
Failed to ensure menus were accurate and reflected correct dietary orders for residents.
Failed to store food under proper sanitation and food handling practices in the central kitchen, including unlabeled opened containers, cross contamination risks, and unclean utensils.
Failed to ensure employees had valid criminal background checks; four employees worked despite ineligible background checks and pending variances.
Failed to complete daily maintenance checks on emergency code carts and failed to maintain temperature monitoring for a unit freezer.
Report Facts
Residents sampled: 16
Residents affected: 5
Days code cart checked: 14
Days code cart checked: 9
Hours worked: 241.75
Hours worked: 193.75
Hours worked: 305.25
Hours worked: 229.15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Employee worked despite background check ineligibility |
| NH #1 | Neighborhood Helper | Employee worked despite background check ineligibility |
| [NAME] #2 | Cook | Employee worked despite background check ineligibility |
| Housekeeper #1 | Housekeeper | Employee worked despite background check ineligibility |
| Director of Nursing | Director of Nursing | Named in medication reconciliation and self-administration assessment findings |
| MDS Coordinator | MDS Coordinator | Named in MDS assessment and care plan deficiencies |
| Pharmacist | Pharmacist | Named in medication reconciliation findings |
| Dietary Manager | Dietary Manager | Named in dietary order and food storage findings |
| Human Resources Director | Human Resources Director | Named in background check findings |
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