Polaris Extended Care

Inspectors wroteBased on record review and interview, the facility failed to ensure the transfer or discharge of 1 resident (#1), out of 4 residents reviewed for transfer and discharge requirements, met the requirements of 42 CFR S483.15(c). Specifically, after determining Resident #1 would not return to the facility following hospitalization, the facility failed to establish and document the basis for the discharge, identify the specific resident needs the facility could not meet, document the facility's attempts to meet those needs, and identify the services available at the receiving facility to meet the resident's needs. This deficient practice placed the resident at risk of inappropriate discharge and disruption in continuity of care necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being

Inspectors wroteBased on record review and interview, the facility failed to provide and document a discharge notice to 1 resident (#1) out of 4 sampled residents after determining that Resident #1 would not be permitted to return to the facility following hospitalization. [...]

Inspectors wroteBased on record review, interview, and observation the facility failed to ensure sufficient nursing staff to meet residents' needs, (based on a census of 93) as established by the facility assessment (a mandatory, comprehensive evaluation to understand the specific resident population's needs and match them with necessary staffing, equipment, and resources to meet those needs). Specifically: The facility assessment identified minimum staffing requirements; however, actual staffing schedules showed fewer certified nursing assistants (CNAs), and licensed nurses (LNs) than defined. Residents (#2 and #3) were not provided ADLs according to their care plans. These deficient practices resulted in delayed residents' care per comprehensive care plans, unmet needs and had the potential to negatively impact residents' health, safety, and quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident representative was informed of, and able to participate in, care decisions for 1 resident (#1) out of 15 residents sampled. Specifically, the facility failed to notify Resident #1's court appointed guardian of a scheduled psychiatric consultation, despite documentation confirming the guardian held full legal authority for medical and mental health treatment decisions. This failed practice prevented the guardian from exercising the right to be informed, to participate in planning of care, and to provide informed consent for mental health services .

Inspectors wroteBased on record review and interview, the facility failed to ensure 2 residents (#2 and #3) out of 15 sampled residents received activities of daily living (ADL) services in accordance with assessed needs, care plans, and stated preferences, resulting in unmet personal care needs and potential diminished quality of life. Specifically, the facility failed to provide scheduled showers to one resident (#2) who was fully dependent on staff for bathing and failed to assist another resident (#3) out of bed as required by the care plan. These failed practices resulted in unmet personal care needs and poor quality of life .

Inspectors wroteBased on record review and interview, the facility failed to ensure necessary care and services were received to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 residents (#6 and #9), out 6 sampled residents. Specifically, the facility failed to: 1) Administer scheduled wound treatment and dressing change orders to Resident #6's right thigh and right buttock on 11/6/25 and 11/8/25; 2) Properly assess reports of increased right leg pain on 11/7-9/25 by Resident #6 and appropriately report this change in condition to providers; and 3) Ensure timely notification for Wound Care Team assessment and interventions for a change in condition of a surgical site for Resident #9's pacemaker (an artificial device surgically placed under the skin for stimulating the heart muscle and regulating its contractions). [...]

Inspectors wroteBased on record review and interview, the facility failed to: 1) Document the reason for resident discharges in the medical record for 3 long-term Residents (#'s 1, 6, and 9), out of 3 resident's reviewed. Specifically, the three residents were discharged without any documentation that showed the residents' welfare and the residents' needs could not be met in the facility; and 2) Document sufficient preparation and orientation to residents and/or resident representatives to ensure safe and orderly discharge from the facility for 3 long-term Residents (#'s 1, 6, and 9), out of 3 resident's reviewed. [...]

Inspectors wroteBased on record review and interview, the facility failed to: 1) Provide a written notice of transfer/discharge, by the facility, at least 30 days before the resident was transferred or discharged for 3 Residents (#'s 1, 6 and 9), out of 3 residents reviewed for transfer/discharge; and 2) Ensure the contents of the notice of transfer/discharge followed regulation requirements. These failed practices denied the resident and/or resident representative appeal rights information that include: 1) The name, address (mailing and email), and telephone number of the entity which receives such requests; 2) Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; 3) The name, address (mailing and email) of the State Long-Term Care Ombudsman; [...]

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse to the State Agency as required under CFR 483.12(c)(1). Not reporting an allegation of abuse in an appropriate and timely manner inhibited the State Agency from accurately assessing and investigating this allegation, which placed all residents at risk for future exposure to potential abuse.

Inspectors wroteBased on record review, interview, and observation, the facility failed to protect the residents right to be from neglect for 3 sampled resident (#'s 40, 47, and 70), out of 21 sampled residents, and 1 unsampled resident (#56). Specifically, the facility failed to ensure provisions of goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress were provided: 1) Activities of Daily Living (ADLs - the skills of bathing, dressing, toileting, transferring, bed mobility, and eating) were completed and/or completed in a timely manner to meet the needs of 1 resident (#40); 2) Medications were available for administration as ordered 2 residents (#47 and #56); and 3) Appropriate, timely treatment for a possible urinary tract infection (UTI) for 1 resident (#70). This failed practice: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate, timely treatment for a possible urinary tract infection (UTI) for 1 resident (#70), out of 21 sampled residents. This failed practice left the resident with UTI symptoms for over a month despite repeated requests for answers and possible treatment from the resident which resulted in continued pain and discomfort.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure: 1) Residents were provided with clear instructions on how to file a grievance; and 2) Consistent and accurate information about the grievance officer's identity was provided. This failed practice denied all residents (based on a census of 91) and their representatives the ability to exercise their rights to file grievances correctly and receive written resolutions of the investigation by the grievance officer.

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse, neglect, and exploitation screening policy accordingly. Specifically, the facility failed to ensure individuals who had direct contact with residents, their medical or financial records, or control over or impact on the financial well-being of residents had a valid criminal history check conducted under 7 Alaska Administrative Code (AAC) 10.900-10.990. This resulted in 37 employees and 18 contracted staff working in the facility without valid clearance from the Alaska Background Check program. This failed practice placed all residents (based on a census of 91) at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and ensure appropriate oversight supervisor of the activity program to support residents in their choice of activities. Specifically, the facility failed to: 1) Ensure activities admission evaluations were completed per established activities program policy for 4 sampled residents (#'s 13; 22; 70; and 292), and 3 unsampled residents (#'s 192, 193, and 293), out of 11 residents reviewed who were admitted since 3/1/25; 2) Ensure the activity director developed, implemented and supervised the activity program which included scheduling of activities, both individual and groups, monitoring the response or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident; [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure their medication error rate was below 5% for 2 sampled residents (#4 and #36) and 2 unsampled residents (#49 and #55), out of 5 residents observed for medication administration. The facility's overall medication error rate was 23.08%. This failed practice placed the residents at risk for adverse medication outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff involved in food preparation, distribution, and service maintained current food handling licenses, called food handler cards, for 24 Night Shift (NOC) staff (#'s 2; 3; 5; 6; 7; 8; 9; 10; 13; 19; 20; 24; 25; 28; 29; 30; 31; 32; 34; 35; 36; 37; 41; and 43), out of 44 NOC staff, and 3 Cooks (#'s 32; 33; and 35), out of 11 Cooks. This failed practice put all 75 residents, who receive food from the kitchen, at risk of health and safety issues due to receiving food prepared and served by unqualified individuals.

Inspectors wroteBased on interview, record review, and observation, the facility failed to: 1) Ensure residents received meals at times and in a manner consistent with their needs, preferences, and requests; and 2) Consistently offer access to suitable snacks or alternative meals outside of scheduled mealtimes to prevent prolonged periods without nourishment. These failed practices placed all 75 residents, who received food from the kitchen, at risk of less-than-optimal nutritional intake and decreased quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure staff were appropriately trained, or with competencies up to date, for direct resident care in 2 cottages, Susitna and Nenana. This failed practice had the potential to create diminished resident care for 23 residents (Susitna Cottage: #'s 2; 3; 24; 26; 33; 45; 46; 52; 60; 68; 71; and 193; Nenana Cottage: #'s 5; 20; 35; 38; 49; 50; 51; 55; 77; 83; and 492) which could affect their overall quality of care and quality of life.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure 4 residents (#s 4, 19, 40, and 48), out of 21 sampled residents, were given the opportunity to make choices about aspects of his/her life that were significant to them. Specifically, the facility failed to ensure residents had the opportunity to: 1) receive a shower and/or a bath; 2) be transferred in and out of bed when requested; and 3) go outside and participate in activities as specified in the plan of care. These failed practices had the potential to affect the resident's quality of life and increase feelings of frustration.

Inspectors wroteBased on record review, interview, and observation, the facility failed to develop and/or implement a comprehensive care plan for 6 Residents (#s 4; 19; 51; 60; 89; and 492), out of 21 sampled residents. Specifically, the facility failed to: 1) implement showers scheduled as care planned; 2) provide adequate supervision and/or assistance to a resident who utilized a ceiling lift; 3) reposition residents and maintain skin integrity as care planned; and 4) develop a care plan for a resident's diagnosis of chronic obstructive pulmonary disease (COPD). These failed practices placed the residents at risk of not receiving necessary care and services to address the individual's needs.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 sampled Residents (#12, #28, #51, and #492), out 21 sampled residents, and 2 unsampled Residents (#74 and #77). Specifically, the facility failed to: 1) Implement and follow individualized turning and repositioning schedules for 3 resident (#'s 12, 51, and #492) with impaired mobility and pressure injury risk; 2) Accurately assess and document the presence of open wounds for 2 residents (#28 and #51); 3) Administer enteral nutrition and medications in accordance with physician orders and clinical standards for 2 resident (#51 and #77); and 4) Provide timely incontinence care for 1 resident (#74). [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed to have sufficient nursing staff to provide care and services for 7 sampled residents (#'s 4; 12; 19; 40; 48; 51; and 492), out of 21 sampled residents, and 1 unsampled resident (#74). Specifically, the facility failed to ensure: 1) Scheduled showers were provided for 3 resident (#'s 4, 19 and 40); 2) Requests to get out of bed to go outside and participate in activities was honored for 1 resident (#48); 3) Timely incontinence care was provided for 1 resident (#74); 4) Scheduled turning and repositioning interventions for 3 residents (#'s 12, 51 and 492) with impaired mobility and at high risk for pressure injuries, were followed. These failed practices placed the residents at risk for not receiving care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, revealed the facility failed to ensure medication and medical supplies were labeled appropriately, and removed from service if expired, in 2 medication carts, out of 8 medication carts inspected, and 1 treatment cart, out of 1 treatment cart inspected. These failed practices had the potential to place the residents at risks of: 1) having inaccurate blood sugar analysis due to expired supplies or the use of an uncalibrated blood sugar monitor; and/or 2) receiving expired medications and supplies which could cause adverse reactions and/or complications.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure medical records were complete and/or accurate for 5 sampled residents (#'s 28; 31; 42; and 343), out of 21 sampled residents, and 1 unsampled resident (#89). This failed practice created incomplete medical records which placed the resident at risk for inconsistencies in treatment and care provided.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents' rights were honored. Specifically, the facility failed to provide care in a manner that promoted dignity and respect for 2 sampled residents (#19 and #51), out of 21 sampled residents, and 1 unsampled resident (#74). This failed practice had the potential to cause psychosocial harm and placed the residents at risk of not attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to fully inform a Resident Representative in advance, of the care to be provided and treatment options for 1 resident (#343), out of 21 sampled residents. This failed practice violated the resident's and resident representative's right to be fully informed and to participate in the resident's treatment.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure reasonable accommodation of needs were maintained for 1 resident (#28), out of 21 sampled residents. Specifically, the facility failed to ensure the resident's call light device was within reach. This failed practice placed the resident at risk for not being able to call for help if needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were deposited into the resident's trust account for 1 resident (#31), out of 21 sampled residents. This failed practice resulted in the resident not having access to their personal funds which violated the resident's right to manage his/her financial affairs.

Inspectors wroteBased on record review and interview, the facility failed to: 1) Provide written information related to bed holds at the time of transfer for 2 residents (#'s 48 and 90), out of 4 residents assessed for hospitalization; and 2) Document a physician's order for discharge for 1 resident (#90), out of 3 closed records reviewed. These failed practices: 1) had the potential for the residents to be displaced from their room or incur charges they would not be aware of from the facility; and 2) created an incomplete medical record.

Inspectors wroteBased on record review and interview, the facility failed to ensure activities of daily living (ADLs) were provided to maintain good personal hygiene for 3 dependent residents (#'s 4, 19, and 40), out of 21 sampled residents. Specifically, the facility failed to assist residents with oral hygiene and bathing as specified in the plan of care. This failed practice had the potential to place residents at risk of poor outcomes from lack of hygiene, infection, and a decreased sense of self-worth.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents received the necessary care and services to monitor for and prevent the development of pressure ulcers for 3 sampled residents (#28, #51, and #492), out of 21 sampled residents. Specifically, the facility failed to: 1) Accurately assess and monitor for wounds for Resident #28; and 2) Consistently turn and reposition 2 residents (#51 and #492). These failed practices had the potential to place the residents at risk for unnecessary pain, increased risk of infection, skin breakdown, and impair the residents' overall health and wellbeing.

Inspectors wroteBased on record review, observation, and interview, revealed the facility failed to ensure 1 unsampled resident (#60) was free from accident hazards. This failed practice had the potential to cause an accident that may have resulted in resident injury.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure safe and appropriate administration of enteral nutrition (the introduction of nutrients directly into the stomach by a soft plastic feeding tube surgically implanted directly through the abdomen) and medication was free of possible complications for 1 sampled resident (#51) and 1 unsampled resident (#77), out of 2 residents reviewed with feeding tubes. Specifically, the facility failed to: 1) Check Resident #51's gastric residual volume prior to initiating enteral nutrition; 2) Ensure Resident #51's head-of-bed remained elevated to an angle of 30 degrees or higher during active feeding; 3) Follow a physician order for flushing Resident #51's feeding tube before and after medication administration; and 4) Use non-contaminated enteral tubing for Resident #77's enteral nutrition. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide necessary respiratory care and services for 2 sampled residents (#2 and #28), out of 21 sampled residents, and 1 resident (#89), out of 3 closed records reviewed. Specifically, the facility failed to: 1) Properly monitor and assess Resident #2's, and #89's supplemental oxygen use; and 2) Ensure written physician orders were in place for oxygen use for Resident #28 and #89. These failed practices placed the residents at risk for not receiving necessary oxygen therapy and not having oxygen therapy appropriately monitored for effectiveness.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure orders for residents' care were provided for 2 sampled residents (#28 and #31), out of 21 sampled residents, and 1 resident (#89), out of 3 closed records reviewed. This failed practice had the potential to place the residents at risk for not receiving the necessary care and services to maintain their highest practicable physical well-being.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure that licensed nursing staff had appropriate competencies, and skill sets necessary to care for resident's needs for 3 residents (#'s 49, 51, and 77), out of 21 sampled residents. Specifically, nursing staff failed to ensure: 1) Medication parameters were met before administration of medications for Resident #49; 2) Approved vital sign equipment was used for resident care in the Nenana cottage; 3) Resident #51's gastric residual volume was checked prior to initiating enteral nutrition; 4) Resident #51's head-of-bed remained elevated to an angle of 30 degrees or higher during active feeding; 5) A physician's order for flushing Resident #51's feeding tube before and after medication administration was followed; 6) Sterility was maintained during tracheostomy care for Resident #51; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure drug regimen review irregularities documented by the pharmacist had a documented review and response from the attending physician and/or medical director for 1 resident (#31), out of 5 residents reviewed for medication regimen reviews. This failed practice placed the resident at risk for adverse outcomes related to the resident's medication therapy, which had the potential to prevent the resident from achieving their highest practicable level of physical, mental and psychosocial well-being.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure 2 sampled residents (#36 and #47), out of 21 sampled residents, and 2 unsampled residents (#49 and #56), were free from significant medication errors. These failed practices caused an adverse reaction of low blood pressure for resident #49 and placed these residents at risk of possible serious complications and hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to provide or obtain dental services to meet the needs of 1 resident (#31), out of 21 sampled residents. This failed practice placed the resident at risk for not receiving the necessary care and services to maintain his/her highest practicable physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food in the kitchen at Susitna and Talkeetna Cottages were prepared, distributed, and served in accordance with professional standards of food safety for 3 residents (#s 29, 37, and 84), out of 19 residents who were receiving food from these kitchens. This failed practice placed the residents at risk of eating contaminated food and at risk of contracting foodborne illness.

Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure: 1) A urinary catheter (a medical device that helps drain urine from the bladder) bag was hung in a manner to remain clean and sanitary for 1 resident (#19), out of 10 residents with indwelling catheters (a tube inserted through the urinary tract into the bladder, connected to a drainage bag); 2) Sterile technique was maintained during tracheostomy care and suctioning for 1 resident (Resident #51), out of 1 resident reviewed for tracheostomy care; 3) Appropriate implementation of droplet precautions for 1 resident (Resident #71), out of 1 resident reviewed for infection control precautions; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure their facility assessment was up to date and accurate. This failed practice had the potential to place all residents (based on a census of 91) at risk for not having the necessary care and resources required for day-to-day operations including nights, weekends, and emergencies.

Inspectors wroteBased on interview and record review, the facility failed to provide routine drugs for 1 resident (#24), out of 15 sampled residents. Specifically, the facility failed to ensure Morphine (an opioid pain medication) was readily available for the relief of pain. This failed practice caused the resident to be in physical pain, and psychosocial distress, for over eight hours without the ability of pain relief.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 resident (#24), out of 15 sampled residents, was free from significant medication errors. This failed practice caused the resident to be in pain and in physical respiratory distress due to a delay and inconsistency in medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1) stored drugs and biologicals were in locked compartments to protect them from unauthorized personnel; and 2) separately locked, permanently affixed compartments for storage of controlled drugs were maintained. Specifically, the medication carts in two out of eight cottages (Kenai and Aniak Cottages) were not secured when Licensed Nurses (LNs) were not in sight of the carts. This failed practice had the potential to allow for diversion and unauthorized access to medications that could have affected the health and safety of all residents in Kenai and Aniak Cottages.

Inspectors wroteBased on record review and interview, the facility failed to honor the rights to choose his/her attending physician for 1 Resident (#3), out of 1 resident reviewed. This failed practice denied the resident the right to choose his/her physician or provided the opportunity for the resident to work with the facility to seek alternate physician participation if his/her choice was unavailable.

Inspectors wroteBased on record review and interview, the facility failed to ensure regular follow up care by a nephrologist (medical doctor who specializes in kidneys) for 1 Resident (#3), out of 1 resident reviewed. This failed practice had the potential to cause the resident to miss needed kidney treatment and care, which had the potential to affect the resident's kidney function and overall health.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure sufficient Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) were available to provide care to all residents, based on a census of 93, as determined by resident acuity (acuity is a measurement of the level of care a resident needs, based on the severity of either an illness or mental condition). This failed practice, to ensure sufficient staff to provide basic nursing care such as turning and repositioning and getting residents out of bed, resulted in harm to residents who developed Stage III, IV, unstageable pressure ulcers and deep tissue injuries. These failed practices caused actual harm due to the of deterioration of pressure ulcers. [...]

Inspectors wroteBased on interview, observation, and record review, the facility administration failed to ensure effective and efficient use of resources to provide for resident safety and to ensure the highest practicable physical, mental, and psychosocial well-being. This placed all residents (based on a census of 93) at risk for physical and/or psychosocial harm. The facility administration failed to maintain the facility in substantial compliance with regulatory requirements which resulted in substandard quality of care in which residents experienced actual physical harm including development of Stage III, IV, and unstageable pressure ulcers and deep tissue injuries. These failed practices caused actual harm due to the of deterioration of pressure ulcers. In addition, failure to ensure adequate staffing to provide for residents' physical, social, and emotional needs caused psychosocial harm. [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, the facility's failed to create and sustain an environment that humanizes and individualizes each resident's quality of life and ensuring that the care and services provided were person-centered, and honored and supported each resident's preferences, choices, and values. This failed practice resulted in psychosocial harm for 10 residents (#s 26, 34, 39, 47, 56, 61, 77, 78, 86, and 92). In addition, these failed practices placed the remaining 83 residents at risk for living and receiving care in a less that optimal environment.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure appropriate treatment and services that includes all care provided to residents to maximize the resident's functional abilities. Specifically, the facility failed to ensure Activities of Daily Living (ADLs - the skills of bathing, dressing, toileting, transferring, bed mobility, and eating) were completed to meet the needs of 8 Residents (#s 26, 34, 39, 47, 61, 78, 86, and 92), out of 20 sampled residents, as determined by resident acuity [acuity is a measurement of the level of care a patient need based on the severity of either an illness or mental condition]. This failed practice resulted in psychosocial harm of these residents. In addition, this failed practice also resulted in two residents (#s 56 and 77) not having ADL needs met. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents in response to allegations of abuse. Specifically, the facility failed to: 1) ensure an alleged perpetrator, Licensed Nurse (LN) #6, was immediately removed from resident care, to prevent further potential abuse, while an active abuse investigation was in progress for 1 sampled resident (#83), out of 1 active abuse investigation reviewed; and 2) ensure an alleged perpetrator, Certified Nurse Assistant (CNA) #2, was kept from 1 unsampled resident (#86), out of 1 past abuse investigation reviewed, after an investigation of abuse was completed. These failed practices caused psychosocial harm to Residents #'s 83 and 86; and placed all residents of the Susitna Cottage (based on a census of 12), and all residents of the Deshka Cottage (based on a census of 11) at risk for further potential abuse.

Inspectors wroteBased on interview and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, from 6/21/24 to 7/15/24 there was no full-time DON for the facility. This failed practice, of not having a full-time DON to provide oversight of nursing staff, including scheduling, responsibilities, and support, placed all residents (based on a census of 93) at substantial risk for subquality of care.

Inspectors wroteBased on interview, observation, and record review, the facility failed to: 1) ensure a dignified dining experience for all who received cooked meals in the Aniak Cottage (based on a census of 12); and 2) respond in a timely manner for assistance for two residents (#34 and #92), out of 20 sampled residents. These failed practices placed the residents at risk for psychological harm from loneliness, feelings of poor self-esteem and a potential for a poor quality of life.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure 2 residents (#34 and #39), out of 20 sampled residents, were able to make choices that were important to them. This failed practice had the potential to affect all residents by denying them the right to make choices that effect their care and quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a homelike dining experience for all residents who received cooked meals in the Aniak cottage (based on a census of 12). This failed practice had the potential to cause a sense of being institutionalized, resulting in diminished self-worth and a reduced sense of well-being.

Inspectors wroteBased on record review and interview, the facility failed to provide written notice which specified the duration of the bed-hold policy and the reserve bed payment policy for 3 residents (#'s 13, 76, and 93), out of 20 sampled residents, who were transferred to the emergency department (ED) for medical treatment. This failed practice had the potential for residents to be uninformed of the facility's bed-hold and reserve bed payment policy, placing them at risk for losing their beds at the facility due to an extended stay at the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure the comprehensive care plan: 1) included the listing of potential serious side effects of medications used, to ensure monitoring was established for resident safety, for 1 resident (#13), out of 20 sampled residents; and 2) included smoking interventions, for resident and cottage safety, for 1 resident (#92), out of 20 sampled residents. These failed practices had the potential to: 1) place the resident #13 at risk for a delay in identifying serious side effects that could affect the resident's health and wellbeing; and 2) place the Aniak Cottage (based on a census of 11) at risk for potential smoke and fire exposure.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure all treatments and care were provided for 4 Residents (#'s 35, 39, 48 and 82), out of 20 sampled residents. This failed practice placed the residents at risk of decreased overall health and wellbeing.

Inspectors wroteBased on record review, interview, and observation, the facility failed to facilitate the necessary treatment and services to promote healing, prevent infections, and prevent new pressure ulcers for 3 residents (#'s 39, 48, and 82), out of 9 sampled residents with pressure ulcer wounds. This failed practice caused pressure injuries for Residents #39 and #82 and impaired Resident #39, #48, and #82's overall health and wellbeing, which had the potential to create the need for hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to maintain accurate contents of dialysis communication binders consistent with professional standards of practice, which was shared between the facility and off-site dialysis centers, for 3 unsampled residents (#'s 40, 54, and 61) and 3 sampled residents (#'s 65, 83, and 87), out of 6 residents who receive off-site dialysis services. This failed practice had the potential to place the residents at risk for inconsistent care, potential for medication errors/interactions, and miscommunication between facilities which could affect overall resident wellbeing and outcome.

Inspectors wroteBased on record review, interview, and observation, the facility failed to: 1) ensure personal protective equipment (PPE) was worn during wound care for 1 resident (#48), out of 9 wound care records reviewed; and 2) ensure proper hand hygiene was performed and completed during wound care treatments for 1 resident (#82), out of 4 wound care treatments observed. This failed practice created potential risk for infection in the wounds, decreased wound healing, and resident well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure the attending provider monitored changing medical status for 1 resident (#48), out of 20 sampled residents. Specifically, Medical Provider #4 failed to monitor weekly laboratory tests that he/she ordered and failed to respond to critically abnormal laboratory results from those tests. This failed practice placed the resident at risk for decompensation and a delay in intervening treatment, which had the potential to create the need for hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to accurately maintain, dispense, and have accountability of controlled drugs for 1 unsampled resident (#54) who received dialysis, out of 6 dialysis residents reviewed. Specifically, the facility sent the controlled drug oxycodone (an opioid pain medication) with the resident when he/she went to dialysis, which inhibited the facility's control and accountability for this medication. This failed practice placed the resident at risk for not receiving this medication and increased the risk of possible loss or diversion of the medication.

Inspectors wroteBased on observation and interview, the facility failed to: 1) discard expired medical supplies in the Nenana cottage; and 2) remove and replace expired medication for 1 resident (#93), out of 12 residents reviewed for medication. These failed practices: 1) placed the residents of the Nenana cottage (based on a census of 11) at risk of receiving expired medical supplies and experiencing potential adverse reactions; and 2) placed resident #93 at risk for not having therapeutic emergent medication during a medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient dietary support staff were available to safely and effectively carry out the functions of the food and nutrition services in 1 cottage (Aniak), out of 8 cottages sampled. This failed practice placed all residents in the Aniak cottage (based on a census of 12), who received meals from the kitchen, at risk to be served meals that did not meet their needs and cause a less than optimal dining experience.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure food and drinks were prepared at a safe and appetizing temperature for 1 resident (#34) in the Aniak cottage (out of 12 residents in the cottage), and all residents who received meals prepared in the Deska cottage (based on a census of 11), out of 8 sampled cottages. Failure of the food to be at a palatable temperature had the potential to lower consumption and place the residents at risk for decreased nutritional intake and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1) food was stored under proper sanitary conditions and stored at safe temperatures for the Aniak and Yukon cottages, out of 4 cottages observed, and 2) staff wore hairnets consistently when in the kitchen for the Matanuska and Kenai cottages, out of 4 cottages observed. This failed practice placed all residents who received food from the affected kitchens, based on a census of 46, at risk for foodborne illness and communicable disease.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to: 1) clearly post the location of available state survey reports in 3 out 8 cottages due to digital displays being down for repairs; and 2) ensure state survey reports were readily accessible to all residents and resident representatives. This failed practice denied residents, resident representatives, and their families of knowing recent facility surveys were available for review and where they were located.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medical supplies were removed from cottage #2 nurse chart room. This failed practice placed the residents of cottage #2 at risk of receiving expired supplies.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure 1 resident (#8), out of 20 sampled residents, was treated in a dignified manner that respected individuality. Specifically, the facility failed to provide a dignified dining experience. This failed practice placed the resident at risk for psychosocial harm such as feelings of poor self-esteem and/or self-worth.

Inspectors wroteBased on record review and interview, the facility failed to obtain informed consent for psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants that would have affected behavior, mood, thoughts, or perception) prior to use for 1 resident (#56) out of 5 sampled residents for unnecessary medications. This failed practice denied the resident the right to consent to medications and be informed of the risk and benefits for medication use.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide reasonable accommodation of needs for 2 Residents (#83 and #86), out of 20 sampled residents. Specifically, the facility failed to ensure the resident's call light device was within reach. This failed practice placed the resident at risk for not being able to call for help or assistance if needed.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure 1 resident (#'s 29) out of 20 sampled residents lived with comfortable sound levels in their bedroom. Specifically, excessive noise from medical equipment interfered with the resident's hearing and the sound levels were out of the resident's control. This failed practice denied the resident a homelike environment and placed the resident at risk for psychological harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a follow-up communication to the resident or resident representative (RR) to resolve a grievance was conducted. Specifically, the facility failed to provide a resolution letter after missing property was reported for 1 resident (#51) out of 20 sampled residents. The failure to follow the grievance process denied residents and/or their representatives the ability to exercise their rights by filing grievances and receiving written resolutions of investigations.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure 1 resident (#70), out of 2 residents sampled for restraints, 1) had a mitten restraint removed per the frequency of the physician's orders and 2) interventions were developed and implemented to potentially reduce the use of the mitten restraint. These failed practices had the potential to increase the resident's agitation and anxiety and deny the resident from attaining their highest practicable well-being.

Inspectors wroteBased on interview and record review the facility failed to failed to notify the State Long-Term Care Ombudsman (LTCO) of transfers and discharges in a timely manner for 2 Residents (#51 and #86), out of 20 sampled residents. This failed practice did not afford these residents their right for continued advocacy and support provided by the LTCO.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure the baseline care plan/ resident daily care plan (RDCP) and comprehensive care plan were consistent with residents care needs for 1 resident (#83), out of 20 sampled residents . This failed practice placed the resident at risk for not receiving necessary services to address his/her individual needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure the comprehensive care plan was updated to meet the needs of 1 resident (#7) out of 20 sampled residents. This failed practice had the potential to cause an inconsistent provision of treatment and services.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide activities of daily living, specifically, nail care for 1 resident (#83), out of 20 sampled residents. This failed practice placed the resident at risk for poor outcomes from lack of hygiene and potential risk for infection.

Inspectors wroteBased on record review and interview, the facility failed to ensure: 1) the physician's PRN (as needed) orders for an antipsychotic medication had not exceeded 14 days; and 2) the prescribing practitioner evaluated the resident prior to ordering the medication for 1 resident (#87), out of 5 residents sampled for unnecessary medications. These failed practices placed the resident at risk for adverse effects and/or reaction from potentially unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the quality of laboratory services. Specifically, 1) control solutions for the glucometer used in cottage #2 were not labeled with open dates when in use; and 2) lab supplies in cottage #1 and #2 were expired. These failed practices had the potential to affect resident testing results.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was protected from cross contamination during distribution. Specifically, meals were delivered uncovered to 6 residents (#'s 11; 68; 89; 33; 80; & 56) out of 12 residents in Cottage #1. This failed practice had the potential for contamination of the food items and placed residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a sanitary environment for 10 Residents (#'s 11; 29; 33; 51; 56; 61; 68; 70; 86; and 89) out of a census of 96 residents. This failed practice had the potential to increase the development and transmission of communicable disease and infections.