Yukon Kuskokwim Elder's Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethel, Alaska.
- Location
- 1100 Chief Eddie Hoffman Hwy, Bethel, Alaska 99559
- CMS Provider Number
- 025037
- Inspections on file
- 18
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Yukon Kuskokwim Elder's Home during CMS and state inspections, most recent first.
A facility used a decolonization protocol involving CHG soap substitution and mupirocin nasal swabs for multiple residents, but the MD stated residents and/or their representatives were not notified and the protocol was not discussed in care conferences. The DON found no documentation of notification, and the Administrator confirmed the planned resident council, ombudsman notice, and admission packet letter were not implemented. The facility’s rights documents stated residents have the right to information about treatments, risks, side effects, and to refuse proposed care.
The facility failed to provide accurate grievance officer contact information and clear instructions for submitting grievances. Posted notices identified a former Grievance Officer, while the admission agreement and grievance form did not explain how or where to submit a completed grievance. Residents stated they did not know who the GO was or how to formally file a complaint, and complaints were often handled informally through staff or the DON.
Food items were found unlabeled, improperly dated, and in some cases expired or without expiration information in the meal prep refrigerator, walk-in freezer, dry storage, and Wing B kitchen. Surveyors also observed tightly stacked boxes stored too close to the ceiling and sprinkler heads in the freezer and refrigerator areas. The KM stated labeling, dating, and storage expectations were taught mainly by verbal instruction and demonstration, and the Dietitian reported inconsistencies in labeling, training, and monitoring.
Failure to Monitor Decolonization Program in QAPI: The facility used a decolonization protocol involving CHG bathing and mupirocin nasal ointment for multiple residents, but there was no evidence that the program was tracked, trended, or monitored through QAPI. The MD said the protocol was a performance improvement initiative and that he was tracking it, but it was not reported in QAPI meetings, the IP was not actively involved in monitoring it, and QAPI minutes did not discuss the program.
Failure to Provide Individualized Resident Activities: Two residents with diagnoses including CHF, hemiparesis, dementia, OA, and a coccyx pressure ulcer had activity plans calling for regular group and individual programming based on their stated interests, but survey findings showed the posted calendar did not match the documentation, residents were mostly observed in their rooms, and one resident reported only bingo and little else. Residents and the resident council described limited, repetitive programming, while staff said CareTracker did not accurately reflect actual participation and the AD was overseeing the program remotely with limited on-site oversight.
The facility did not have a full-time DON from late March through late May, as the previous DON resigned and the new DON did not assume the role until the end of May. During this period, the responsibilities of the DON, such as overseeing nursing services and ensuring compliance, were not formally assigned or fulfilled.
Surveyors found multiple expired and unlabeled food items in the kitchen's cooler, freezer, dry storage, and meal prep areas. Staff could not provide expiration dates for several products, and food rotation practices were not consistently followed, contrary to facility policy. These deficiencies had the potential to cause or spread foodborne illness among residents receiving food from the kitchen.
Staff did not provide hand hygiene to multiple residents before meals or after bathroom use, including a resident with dementia who was not offered hand hygiene after perineal care. Additionally, clean laundry was transported in uncovered bins through common areas and into residents' rooms, contrary to facility policy requiring covered containers.
Multiple residents with complex medical conditions were found to have bed rails in use without documented physician orders, risk and benefit assessments, or informed consent. Staff confirmed that no policy or formal process was in place for bed rail assessment or consent, and medical records did not reflect the use of bed rails despite direct observation.
Five residents with complex medical conditions were not examined in person by a medical provider within the required intervals, with gaps between visits ranging from 104 to 180 days. The DON reported that residents were seen on admission and quarterly, but there was no written policy for provider visits, and federal guidelines were not consistently followed.
A resident with multiple medical conditions sustained a superficial injury when their wheelchair tipped over during transport in the facility vehicle, despite being secured by two nurses. Review of staff records showed that several employees had not completed required training on the Q-Straint wheelchair restraint system, and facility leadership could not provide proof of training for those who claimed to be trained. Interviews confirmed that staff responsible for securing residents during transport lacked documented competency in the use of the restraint system.
Three residents with multiple chronic conditions did not have required monthly drug regimen reviews completed for two separate months, as confirmed by pharmacy consult note reviews and staff interviews. Pharmacists attributed the missed reviews to prior short staffing, despite facility policy mandating monthly MRRs.
Expired medical supplies, including syringes, bandages, pads, tubing, and distilled water, were found in a supply storage room. An LPN confirmed the items were expired, and the DON stated that LNs were expected to audit and discard such items each shift, primarily on the night shift. Facility policy required removal of expired products, but the expired items remained in storage.
The facility did not update care plans for two residents after significant changes in their conditions. One resident with a history of CHF and other diagnoses had ongoing leg edema documented and treated, but no care plan interventions addressed the edema. Another resident developed a UTI with new symptoms and was prescribed antibiotics, but the care plan was not revised to include this diagnosis or related interventions.
Failure to Inform Residents About Decolonization Protocol
Penalty
Summary
The facility failed to honor the rights of 17 of 18 residents to be informed of, to participate in, or refuse the facility’s decolonization program. Record review showed residents had orders for mupirocin 2% topical ointment applied to both nares twice daily Monday through Friday, and the Medical Director stated the ointment was used as part of the facility’s decolonization protocol. He also stated the facility had been using chlorhexidine gluconate as a soap substitute during shower days and giving mupirocin nasal swabs every other week to remove bacteria in the nose and skin. The Medical Director stated the decolonization protocol was not experimental research and was considered part of the facility’s performance improvement efforts. He stated the residents and/or their representatives were not notified of the protocol, and that he did not discuss it during care conferences unless the topic came up. Licensed Nurse #1 stated residents were receiving mupirocin nasal swabs to bring down infection, but she was not sure what infection was being prevented. The DON stated he found no documentation that residents or their representatives had been notified, and the Administrator stated there should have been notification. Review of the facility’s Decolonization QAPI program showed planned resident communication activities including discussion at Resident Council, Ombudsman notification, and a letter in the admission packet, but the facility did not provide documentation that these approaches were used. The Administrator later stated the resident council, ombudsman notice, and admission packet letter were from a template from another organization and were neither adopted nor implemented. The facility’s posted rights statement and admission packet stated residents have the right to receive information about procedures and treatments, known risks and side effects, and to refuse proposed procedures and treatments without involvement in research or experimental procedures without knowledge and consent.
Grievance Process Information Was Inaccurate and Incomplete
Penalty
Summary
The facility failed to ensure that accurate grievance officer contact information was available to residents and representatives through required postings or individual notice, and failed to provide clear instructions on how to file and submit grievances. During observations, the grievance notice posted in residents’ rooms listed Grievance Officer #1 with contact information, but that individual was no longer the facility’s current designated Grievance Official. The Administrator stated she had assumed responsibility for the grievance process in October 2025 after identifying a need for more formal tracking, and that the prior Social Worker had handled grievances before that time. The Administrator stated residents were generally informed about the grievance process through staff rather than formal postings, and that complaints were commonly routed through nursing staff or placed in a box. She also stated that grievance information should be included in the admission packet, but acknowledged that detailed instructions on the grievance form or process were not currently being included. Review of the admission agreement showed residents and families were told they could discuss concerns with the DON, Social Services, or Administrator, and that a grievance form was located in the lobby, but the document did not include instructions for submitting the completed form, where it should be submitted, or who the designated grievance officer was. The grievance form itself also did not include submission instructions. During a Resident Council interview, residents stated they did not know who the Grievance Officer was or how to formally submit a grievance. They were uncertain who they would go to with a complaint, and several residents said they were not aware of a formal grievance system or how to submit complaints in writing. One resident stated they did not speak up when first admitted because they did not know what was going on and did not know there were complaints. Another resident reported that a resident with missing items was reluctant to report the issue because they were scared to ask.
Food Storage, Labeling, and Clearance Deficiencies
Penalty
Summary
Food was not stored, labeled, and prepared in accordance with professional standards of practice for food safety. During the main kitchen tour, surveyors observed an open half-gallon carton of milk in the meal prep refrigerator that was unlabeled, a clear plastic bag of hot dogs in the walk-in freezer that was unlabeled and dated 3/1/26, and a clear plastic bag of Salisbury steak in the freezer that was unlabeled and had no best-used-by or expiration date. In dry storage, 26 packages of grape cranberry juice drink were found with a best-by date of 2/15/26. In the Wing B kitchen, a plastic bag containing an unidentified food item resembling white bread was also unlabeled and had no best-used-by or expiration date. Surveyors also observed storage conditions in the walk-in freezer and refrigerator that did not maintain the required clearance from sprinkler heads. Multiple rows of tightly stacked cardboard boxes were stored on metal wire shelving from the floor to the ceiling, with approximately 1 to 3 inches between the top box and the ceiling. The storage areas were described as congested and cluttered, with limited spacing between items, and several boxes were very close to two large industrial cooling fans. During interview, the Kitchen Manager stated staff were expected to write the name on items, store them, and routinely check refrigerators, freezers, and dry storage for proper labeling and dating. He/she confirmed that expired or mislabeled items would be discarded, but also stated that training was mainly verbal and demonstrated by showing new staff what to do. The Kitchen Manager said the facility followed a storage policy requiring items to be kept 18 inches from the ceiling, but described the instruction as something he/she told staff about verbally. The Dietitian reported serving 18 residents, noted inconsistencies in labeling practices, training, and monitoring, and stated that he/she worked remotely and did not have direct hands-on capability to ensure compliance.
Failure to Monitor Decolonization Program in QAPI
Penalty
Summary
The facility failed to monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Survey findings showed there was no evidence that the facility tracked, trended, or monitored its decolonization program, which was described by the Medical Director as a performance improvement initiative. The deficiency was identified during interview and record review, and it involved the facility’s use of chlorhexidine gluconate as a soap substitute during shower days and mupirocin 2% topical nasal ointment given on a recurring schedule. Record review showed that multiple residents had orders for mupirocin topical ointment, with 17 residents having completed courses documented over varying lengths of time. The quarterly MDS records also showed 15 residents had antibiotics checked as being taken with an indication noted. In addition, the medical record review showed that 16 residents had a diagnosis of Encounter for Prophylaxis. The Medical Director stated the mupirocin was used for the facility’s decolonization protocol to remove bacteria in the nose and skin. During interviews, the Administrator stated QAPI was tracking and trending other projects such as pressure injuries, but the decolonization program was not discussed in QAPI meetings. The Infection Preventionist stated she was aware chlorhexidine was being used and that nasal swabs were being initiated, but she was not actively involved in monitoring the program. The Medical Director stated he had implemented the decolonization program after reviewing a webinar and article, that he was tracking and trending the program, and that he had not reported or updated QAPI on it. Review of QAPI minutes dated 12/18/25, 1/15/26, and 2/19/26 showed the decolonization program was not discussed, and the facility’s QAPI plan stated that ongoing monitoring of PIPs would be documented and reported to QAPI on a regular basis.
Failure to Provide Individualized Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of individualized, meaningful activities designed to meet the interests and needs of two sampled residents. For one resident, the record showed diagnoses including heart failure with hemiparesis, hyperlipidemia, hypertension, insomnia, and colorectal cancer. The resident’s activity evaluation identified interests in card games, crafts, fishing-net related handwork, walking, music, Bible reading, worship, movies, seasonal events, and sightseeing. The care plan stated the resident would participate in group activities five times per week and be involved in individual activities daily, with interests including country and gospel music, Yup'ik radio call-in shows, TV/movies, outings, storytelling, fishing nets, Alaska Native culture, socials, and sports. For the second resident, the record showed diagnoses including chronic low back pain, microalbuminuria, osteoarthritis, a coccyx pressure ulcer, and dementia. The resident’s activity evaluation identified interests in bingo, hand crafts, low-impact exercise, music, mail, worship, movies, seasonal events, sightseeing, and social conversation with family, other residents, staff, and volunteers. The care plan stated the resident would participate in group activities five times per week and independent activities of choice daily, with interests including bingo, cooking, crafts, exercise, music/radio, church, TV/movies, van rides, community events, Native Alaskan culture, socializing, and mail. Survey findings showed that the activity documentation for both residents did not align with the posted activity calendar and did not clearly show individualized or goal-directed activities being provided as planned. Random observations throughout the survey found both residents were consistently observed in their rooms and were not observed participating in or being offered scheduled group or individual activities, with one resident observed participating in bingo only once. During resident council, multiple residents stated they had very limited activity options, that bingo was the only activity they were aware of, and that no activities were offered on the day of the interview. Staff also stated the facility did not have an effective way to accurately track or log activities, that CareTracker did not reflect actual participation, and that refusals could not be documented in the system. The Activities Director stated she was overseeing the program remotely, had not been on site since COVID, relied heavily on staff input, did not create the calendar because she was not there, and had fallen behind on audits and QAPI reviews.
Failure to Designate Full-Time DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis from the end of March 2024 through the end of May 2024. During this period, the previous DON, who was also the Chief Nursing Officer (CNO) at the Yukon Kuskokwim Delta Regional Hospital, resigned from the DON position effective mid-March 2024. Interviews confirmed that there was no designated full-time DON during this time, and the CNO did not provide a response when asked who was fulfilling the DON role. The new DON only accepted the position at the end of May 2024, and prior to that, worked as a charge nurse. Review of facility documentation showed that the responsibilities of the DON include overseeing the delivery of nursing services, ensuring adequate staffing, maintaining compliance, and keeping the administrator informed of changes. The job description for the charge nurse also indicated the need to report changes in resident condition to the DON, highlighting the importance of the DON role in daily operations. The absence of a full-time DON during the specified period meant that these responsibilities were not formally assigned or fulfilled.
Expired and Unlabeled Food Items Found in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to store, label, and prepare food in accordance with professional standards for food safety. During a kitchen tour, multiple expired food items were found in the walk-in cooler, walk-in freezer, dry storage, and meal prep areas, including expired dairy products, yogurt, chopped garlic, honey, peanut butter, cake mix, and food thickener. Additionally, several food items were not labeled or dated, such as bags of oxtail, duck, bread, and containers of flour and panko. Staff interviews revealed that food rotation practices were in place, but staff were unable to provide expiration dates or clarify how long unlabeled products were kept. The facility's own policies require that all food be procured, stored, handled, prepared, distributed, and served in accordance with safe food handling and storage practices established by state and federal agencies. However, observations showed that these policies were not consistently followed, as evidenced by the presence of expired and unlabeled food items in various storage areas. These practices had the potential to cause or spread foodborne illness to the facility's residents, all of whom received food from the kitchen.
Failure to Provide Hand Hygiene and Proper Laundry Transport
Penalty
Summary
The facility failed to follow infection prevention and control practices, specifically in the areas of hand hygiene and laundry transport. During multiple dining observations, staff did not offer hand hygiene to several residents before meals. Certified Nurse Assistants (CNAs) and a Licensed Nurse (LN) were observed serving meals to residents without providing hand hygiene, despite facility policy requiring hand hygiene before and after meals. This was observed on several occasions, with residents being served food in the dining area without being offered the opportunity to clean their hands. Additionally, hand hygiene was not provided to a resident after bathroom use. On two separate occasions, a resident with dementia, anxiety, and insomnia was assisted to the bathroom by CNAs. After perineal care and changing of briefs, the resident was returned to the dining area and served lunch without being offered hand hygiene. In one instance, feces fell onto the bathroom floor and was picked up by a student CNA, but the floor was not cleaned and the resident was not given hand hygiene before returning to the dining area. The facility also failed to ensure that clean laundry was transported in a manner that prevented contamination. Clean laundry was placed in an uncovered blue bin and moved through common areas and into residents' rooms without a cover, contrary to facility policy which requires clean laundry to be delivered in a covered container. Staff interviews confirmed that the clean laundry bins were not covered during transport.
Failure to Obtain Consent and Assess Risks for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent and conduct accurate risk and benefit assessments prior to the use of bed rails for multiple residents. Record reviews, observations, and interviews revealed that for at least nine residents, bed rails were in use without any documented physician order, assessment of risks and benefits, or informed consent from the resident or their representative. This was confirmed through both direct observation of bed rails in use and review of medical records, which consistently lacked the required documentation. Residents affected had a range of diagnoses, including Alzheimer's disease, dementia, chronic kidney disease, type 2 diabetes mellitus, major depressive disorder, aortic valve regurgitation, gait disorder, seizure disorder, rheumatoid arthritis, Lewy body dementia, anxiety, insomnia, and benign prostatic hyperplasia. Despite these complex medical conditions and impaired activities of daily living, the facility did not complete the necessary assessments or obtain consent for bed rail use. In several cases, the most recent Minimum Data Set (MDS) assessments indicated that bed rails were not in use, contradicting direct observations. Interviews with facility staff, including the Director of Nursing and a Certified Nursing Assistant, confirmed that there was no policy in place for bed rail assessment, and that the facility did not obtain consent or complete risk and benefit assessments for side rail usage. The DON acknowledged the absence of a bedrail assessment policy, and the CNA stated that bed rails were used to promote mobility, but no formal process was followed to ensure resident safety or compliance with regulatory requirements.
Failure to Ensure Timely In-Person Physician Visits
Penalty
Summary
The facility failed to ensure that five residents were examined in person by a medical provider within the required intervals, as mandated by federal guidelines. Record reviews revealed that these residents, who had complex medical conditions such as osteoarthritis, congestive heart failure, dementia, depression, chronic kidney disease, rheumatoid arthritis, peripheral vascular disease, diabetes mellitus, and cancer, did not receive timely in-person visits from their physicians. The intervals between physician visits for these residents ranged from 104 to 180 days, exceeding the required maximum of 60 days or no later than 10 days after the required visit date. During interviews, the DON stated that residents were seen on admission and quarterly, but could not provide a facility policy specific to provider visits. The DON later indicated that the medical director follows federal guidelines for visit timing, but this was not documented in a written policy. The lack of adherence to required visit intervals and absence of a formal policy resulted in residents not being seen in person by a medical provider as frequently as required.
Failure to Ensure Staff Competency in Wheelchair Restraint Use During Resident Transport
Penalty
Summary
The facility failed to ensure that staff received proper education and training on the use of the Q-Straint QRT-1 Series Wheelchair Restraint system, which is used to secure wheelchair-bound residents during transport in the facility vehicle. Record review revealed that a resident with diagnoses including Alzheimer's disease, anemia, and atrial fibrillation sustained a superficial laceration to the right temple after their wheelchair tipped over while being transported in the facility vehicle. The incident occurred despite the wheelchair being secured by two licensed nurses, whose identities could not be confirmed by facility leadership during interviews. Further review of staff training records showed that several staff members assigned to complete the required transport restraint training had not done so, and active employees were working with residents without documented completion of this training. Interviews with the DON and a CNA indicated that only a few staff members had reportedly been trained, but no proof of this training could be produced. Additionally, one CNA who regularly secured residents in the transport vehicle stated they had not completed a HealthStream skills check-off for the Q-Straint system.
Failure to Complete Monthly Drug Regimen Reviews Due to Pharmacy Staffing Issues
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews (MRRs) were completed for three residents, as required by facility policy. Record reviews for these residents showed that MRRs were not performed for the months of September and December 2024. The residents affected had multiple complex diagnoses, including osteoarthritis, congestive heart failure, dementia, depression, impaired mobility, rheumatoid arthritis, peripheral vascular disease, Lewy body dementia, anxiety, and insomnia. The absence of documented MRRs was confirmed through review of pharmacy consult notes covering January 2024 through January 2025. Interviews with two pharmacists revealed that the standard practice was to complete and document MRRs monthly in the residents' charts. Both pharmacists acknowledged that the MRRs for the specified months were not completed, attributing the lapse to previous short staffing in the pharmacy department. Review of the facility's policy confirmed the requirement for monthly drug regimen reviews of each resident's medical chart.
Expired Medical Supplies Not Removed from Storage
Penalty
Summary
Expired medical supplies were found in one of the facility's medical supply storage rooms during an observation. The expired items included syringes, self-adherent bandages, non-adhesive pads, non-adherent pad prepacks, suction connection tubing, and distilled water, all of which were past their labeled expiration or best by dates. These findings were confirmed by a licensed nurse during an interview, who acknowledged that the supplies were expired. The Director of Nursing stated that licensed nurses were expected to audit and discard expired medical supplies, with the primary responsibility falling on the night shift. However, the presence of expired items indicated that these audits were not being performed as required. A review of the facility's policy confirmed that designated staff were responsible for inspecting storage areas and removing expired or soon-to-expire products from inventory.
Failure to Update Care Plans for Edema and UTI
Penalty
Summary
The facility failed to revise and update care plans for two residents following changes in their medical conditions. For one resident with a history of vascular dementia, stroke, seizure disorder, congestive heart failure, and asthma, multiple clinical notes and interviews confirmed the presence of bilateral lower extremity edema over a period of several months. Despite ongoing documentation of swelling and the administration of Furosemide for edema, the resident's care plan did not include any interventions specifically addressing edema. Observations also noted visible swelling in the resident's legs. For another resident with a history of malnutrition and stroke, clinical records and interviews indicated the onset of urinary symptoms, including difficulty urinating, incontinence, and suprapubic pain, which led to a diagnosis of urinary tract infection (UTI). Although the resident was prescribed antibiotics for the UTI, the care plan was not updated to reflect this new diagnosis or the interventions required. The facility's own policy required individualized, interdisciplinary care plans to address residents' medical needs, but in both cases, the care plans were not revised in response to significant changes in the residents' conditions.
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.
A resident’s care plan was not revised to reflect a new PTSD diagnosis. The MDS listed chronic PTSD as an active diagnosis, but LTC care conference notes did not discuss it and the care plan had no related problem, outcomes, or interventions. The resident reported that loud noises triggered war-related memories, and the DON stated she was unaware of the resident’s specific PTSD triggers and confirmed the diagnosis should have been incorporated into the care plan.
Missed Mealtime Insulin Administration: A resident with DM, mild dementia, and anemia missed 74 ordered mealtime sliding scale insulin doses because staff documented the doses as not given due to the resident being asleep or due to nursing judgment. A nurse stated the facility would hold meds when the resident was sleeping and referenced an order that could not be produced in the EHR. The MAR and BG records showed repeated elevated BG readings during missed insulin opportunities, and the facility policy identified mealtime insulin as time-critical medication.
A facility used a decolonization protocol involving CHG soap substitution and mupirocin nasal swabs for multiple residents, but the MD stated residents and/or their representatives were not notified and the protocol was not discussed in care conferences. The DON found no documentation of notification, and the Administrator confirmed the planned resident council, ombudsman notice, and admission packet letter were not implemented. The facility’s rights documents stated residents have the right to information about treatments, risks, side effects, and to refuse proposed care.
The facility failed to provide accurate grievance officer contact information and clear instructions for submitting grievances. Posted notices identified a former Grievance Officer, while the admission agreement and grievance form did not explain how or where to submit a completed grievance. Residents stated they did not know who the GO was or how to formally file a complaint, and complaints were often handled informally through staff or the DON.
Food items were found unlabeled, improperly dated, and in some cases expired or without expiration information in the meal prep refrigerator, walk-in freezer, dry storage, and Wing B kitchen. Surveyors also observed tightly stacked boxes stored too close to the ceiling and sprinkler heads in the freezer and refrigerator areas. The KM stated labeling, dating, and storage expectations were taught mainly by verbal instruction and demonstration, and the Dietitian reported inconsistencies in labeling, training, and monitoring.
Failure to Monitor Decolonization Program in QAPI: The facility used a decolonization protocol involving CHG bathing and mupirocin nasal ointment for multiple residents, but there was no evidence that the program was tracked, trended, or monitored through QAPI. The MD said the protocol was a performance improvement initiative and that he was tracking it, but it was not reported in QAPI meetings, the IP was not actively involved in monitoring it, and QAPI minutes did not discuss the program.
Failure to Provide Individualized Resident Activities: Two residents with diagnoses including CHF, hemiparesis, dementia, OA, and a coccyx pressure ulcer had activity plans calling for regular group and individual programming based on their stated interests, but survey findings showed the posted calendar did not match the documentation, residents were mostly observed in their rooms, and one resident reported only bingo and little else. Residents and the resident council described limited, repetitive programming, while staff said CareTracker did not accurately reflect actual participation and the AD was overseeing the program remotely with limited on-site oversight.
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.
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.
Care Plan Not Updated for Resident’s PTSD Diagnosis
Penalty
Summary
The facility failed to update and revise the care plan for one sampled resident after a new diagnosis of chronic PTSD was entered into the record. Resident #5 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction. Record review showed a diagnosis of chronic PTSD first entered on 9/10/25, and a second PTSD diagnosis later entered on 2/25/26. The quarterly MDS assessment dated 12/8/25 listed PTSD, chronic, as an active diagnosis, and that diagnosis remained on subsequent assessments. Review of the resident’s quarterly LTC care conference notes from 9/24/25, 12/25/25, and 3/9/26 showed no discussion of the PTSD diagnosis. The care plan, last reviewed on 3/5/26, did not include a problem, outcomes, or interventions related to PTSD. During interview, the resident stated that loud noises such as doors slamming or the snow removal machine outside the room triggered memories of mortar shells and rockets from the war. The DON stated she was unaware of the resident’s specific PTSD triggers and confirmed the diagnosis should have been incorporated into the care plan.
Missed Mealtime Insulin Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure that one resident with diabetes mellitus consistently received ordered mealtime sliding scale insulin. Resident #3 was admitted with diagnoses that included diabetes mellitus, mild dementia, and anemia, and the care plan stated that the resident required medication management daily and would be provided medications as ordered. The physician order for insulin aspart required subcutaneous administration after meals using a sliding scale based on blood glucose results. Record review showed that from 10/3/25 through 3/9/26, Resident #3 missed 74 insulin administrations. The MAR documented 72 missed doses with the rationale of "Patient Asleep" and 2 missed doses with the rationale of "Nursing Judgement." During an observation on 3/11/26 at 8:20 AM, a nurse withheld the resident's morning insulin dose and stated that the facility's process was to document the medication as not administered when the resident was sleeping. The nurse also stated there was a physician communication order allowing medications to be held if the resident was asleep, but could not produce documentation supporting that statement in the EHR. Review of the blood glucose records in relation to the missed insulin opportunities showed elevated readings during the periods when insulin was not administered, including multiple values above the ordered sliding scale thresholds. The resident stated that the insulin was very important and expected to be woken up when it was due. The facility policy identified mealtime insulin as time-critical medication and required administration within 30 minutes of the intended time, and the nursing standard required documentation of the reason when a medication was not administered.
Failure to Inform Residents About Decolonization Protocol
Penalty
Summary
The facility failed to honor the rights of 17 of 18 residents to be informed of, to participate in, or refuse the facility’s decolonization program. Record review showed residents had orders for mupirocin 2% topical ointment applied to both nares twice daily Monday through Friday, and the Medical Director stated the ointment was used as part of the facility’s decolonization protocol. He also stated the facility had been using chlorhexidine gluconate as a soap substitute during shower days and giving mupirocin nasal swabs every other week to remove bacteria in the nose and skin. The Medical Director stated the decolonization protocol was not experimental research and was considered part of the facility’s performance improvement efforts. He stated the residents and/or their representatives were not notified of the protocol, and that he did not discuss it during care conferences unless the topic came up. Licensed Nurse #1 stated residents were receiving mupirocin nasal swabs to bring down infection, but she was not sure what infection was being prevented. The DON stated he found no documentation that residents or their representatives had been notified, and the Administrator stated there should have been notification. Review of the facility’s Decolonization QAPI program showed planned resident communication activities including discussion at Resident Council, Ombudsman notification, and a letter in the admission packet, but the facility did not provide documentation that these approaches were used. The Administrator later stated the resident council, ombudsman notice, and admission packet letter were from a template from another organization and were neither adopted nor implemented. The facility’s posted rights statement and admission packet stated residents have the right to receive information about procedures and treatments, known risks and side effects, and to refuse proposed procedures and treatments without involvement in research or experimental procedures without knowledge and consent.
Grievance Process Information Was Inaccurate and Incomplete
Penalty
Summary
The facility failed to ensure that accurate grievance officer contact information was available to residents and representatives through required postings or individual notice, and failed to provide clear instructions on how to file and submit grievances. During observations, the grievance notice posted in residents’ rooms listed Grievance Officer #1 with contact information, but that individual was no longer the facility’s current designated Grievance Official. The Administrator stated she had assumed responsibility for the grievance process in October 2025 after identifying a need for more formal tracking, and that the prior Social Worker had handled grievances before that time. The Administrator stated residents were generally informed about the grievance process through staff rather than formal postings, and that complaints were commonly routed through nursing staff or placed in a box. She also stated that grievance information should be included in the admission packet, but acknowledged that detailed instructions on the grievance form or process were not currently being included. Review of the admission agreement showed residents and families were told they could discuss concerns with the DON, Social Services, or Administrator, and that a grievance form was located in the lobby, but the document did not include instructions for submitting the completed form, where it should be submitted, or who the designated grievance officer was. The grievance form itself also did not include submission instructions. During a Resident Council interview, residents stated they did not know who the Grievance Officer was or how to formally submit a grievance. They were uncertain who they would go to with a complaint, and several residents said they were not aware of a formal grievance system or how to submit complaints in writing. One resident stated they did not speak up when first admitted because they did not know what was going on and did not know there were complaints. Another resident reported that a resident with missing items was reluctant to report the issue because they were scared to ask.
Food Storage, Labeling, and Clearance Deficiencies
Penalty
Summary
Food was not stored, labeled, and prepared in accordance with professional standards of practice for food safety. During the main kitchen tour, surveyors observed an open half-gallon carton of milk in the meal prep refrigerator that was unlabeled, a clear plastic bag of hot dogs in the walk-in freezer that was unlabeled and dated 3/1/26, and a clear plastic bag of Salisbury steak in the freezer that was unlabeled and had no best-used-by or expiration date. In dry storage, 26 packages of grape cranberry juice drink were found with a best-by date of 2/15/26. In the Wing B kitchen, a plastic bag containing an unidentified food item resembling white bread was also unlabeled and had no best-used-by or expiration date. Surveyors also observed storage conditions in the walk-in freezer and refrigerator that did not maintain the required clearance from sprinkler heads. Multiple rows of tightly stacked cardboard boxes were stored on metal wire shelving from the floor to the ceiling, with approximately 1 to 3 inches between the top box and the ceiling. The storage areas were described as congested and cluttered, with limited spacing between items, and several boxes were very close to two large industrial cooling fans. During interview, the Kitchen Manager stated staff were expected to write the name on items, store them, and routinely check refrigerators, freezers, and dry storage for proper labeling and dating. He/she confirmed that expired or mislabeled items would be discarded, but also stated that training was mainly verbal and demonstrated by showing new staff what to do. The Kitchen Manager said the facility followed a storage policy requiring items to be kept 18 inches from the ceiling, but described the instruction as something he/she told staff about verbally. The Dietitian reported serving 18 residents, noted inconsistencies in labeling practices, training, and monitoring, and stated that he/she worked remotely and did not have direct hands-on capability to ensure compliance.
Failure to Monitor Decolonization Program in QAPI
Penalty
Summary
The facility failed to monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Survey findings showed there was no evidence that the facility tracked, trended, or monitored its decolonization program, which was described by the Medical Director as a performance improvement initiative. The deficiency was identified during interview and record review, and it involved the facility’s use of chlorhexidine gluconate as a soap substitute during shower days and mupirocin 2% topical nasal ointment given on a recurring schedule. Record review showed that multiple residents had orders for mupirocin topical ointment, with 17 residents having completed courses documented over varying lengths of time. The quarterly MDS records also showed 15 residents had antibiotics checked as being taken with an indication noted. In addition, the medical record review showed that 16 residents had a diagnosis of Encounter for Prophylaxis. The Medical Director stated the mupirocin was used for the facility’s decolonization protocol to remove bacteria in the nose and skin. During interviews, the Administrator stated QAPI was tracking and trending other projects such as pressure injuries, but the decolonization program was not discussed in QAPI meetings. The Infection Preventionist stated she was aware chlorhexidine was being used and that nasal swabs were being initiated, but she was not actively involved in monitoring the program. The Medical Director stated he had implemented the decolonization program after reviewing a webinar and article, that he was tracking and trending the program, and that he had not reported or updated QAPI on it. Review of QAPI minutes dated 12/18/25, 1/15/26, and 2/19/26 showed the decolonization program was not discussed, and the facility’s QAPI plan stated that ongoing monitoring of PIPs would be documented and reported to QAPI on a regular basis.
Failure to Provide Individualized Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of individualized, meaningful activities designed to meet the interests and needs of two sampled residents. For one resident, the record showed diagnoses including heart failure with hemiparesis, hyperlipidemia, hypertension, insomnia, and colorectal cancer. The resident’s activity evaluation identified interests in card games, crafts, fishing-net related handwork, walking, music, Bible reading, worship, movies, seasonal events, and sightseeing. The care plan stated the resident would participate in group activities five times per week and be involved in individual activities daily, with interests including country and gospel music, Yup'ik radio call-in shows, TV/movies, outings, storytelling, fishing nets, Alaska Native culture, socials, and sports. For the second resident, the record showed diagnoses including chronic low back pain, microalbuminuria, osteoarthritis, a coccyx pressure ulcer, and dementia. The resident’s activity evaluation identified interests in bingo, hand crafts, low-impact exercise, music, mail, worship, movies, seasonal events, sightseeing, and social conversation with family, other residents, staff, and volunteers. The care plan stated the resident would participate in group activities five times per week and independent activities of choice daily, with interests including bingo, cooking, crafts, exercise, music/radio, church, TV/movies, van rides, community events, Native Alaskan culture, socializing, and mail. Survey findings showed that the activity documentation for both residents did not align with the posted activity calendar and did not clearly show individualized or goal-directed activities being provided as planned. Random observations throughout the survey found both residents were consistently observed in their rooms and were not observed participating in or being offered scheduled group or individual activities, with one resident observed participating in bingo only once. During resident council, multiple residents stated they had very limited activity options, that bingo was the only activity they were aware of, and that no activities were offered on the day of the interview. Staff also stated the facility did not have an effective way to accurately track or log activities, that CareTracker did not reflect actual participation, and that refusals could not be documented in the system. The Activities Director stated she was overseeing the program remotely, had not been on site since COVID, relied heavily on staff input, did not create the calendar because she was not there, and had fallen behind on audits and QAPI reviews.
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.
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