Citations in Alaska
Statistics, citations and compliance trends for long-term care facilities in Alaska.
Statistics for Alaska (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Alaska
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 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.
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Compliance trends in Alaska
Data through Feb 2026Comparisons below measure the most recent period Mar 2025 – Feb 2026 against the prior period Mar 2024 – Feb 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Mar 2025 – Feb 2026 vs the prior period Mar 2024 – Feb 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Mar 2025 – Feb 2026 vs the prior period Mar 2024 – Feb 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Mar 2025 – Feb 2026 vs the prior period Mar 2024 – Feb 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Trusted data from CMS and state health departments
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