Denali Center
1510 19th Avenue, Fairbanks, AK 99701 · Non profit - Corporation · 71 certified beds · (907) 458-5100 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,358 in federal fines (most recent 2026-01-20)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.3% | 16.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 9.1% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.2% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.4% | 6.5% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.3% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 20.9% | 19.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.1% | 14.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.8% | 96.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.8% | 6.9% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.6% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.4% | 18.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 0.5% | 1.4% | better than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 81.1% | 85.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 10.1% | 15.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.1% | 11.0% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.21 | 1.00 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.64 | 1.36 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
60.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 101 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 33 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.1%CMS range 52.1–69.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 5.9–13.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 60.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 69.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.7%CMS range 3.3–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.71 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 71 beds and averages 73.6 residents a day — about 104% occupied, or roughly -3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.36 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.32 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.69 hrs/resident/day on weekends vs 5.63 on weekdays — 17% thinner on weekends. RN hours go from 1.18 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2026-01-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure the resident environment was free from accident hazards by failing to monitor and control the temperature of hot beverages provided to 1 resident (#29), out of 18 sampled residents. Specifically, staff served hot coffee from a staff designated coffee pot to a cognitively impaired resident without verifying safe temperature parameters, resulting in burns that required nursing assessment and treatment. This failed practice caused the resident to endure second degree burns and constituted actual harm to the resident. Findings:Record review from 1/11-15/26, revealed Resident #29 was admitted to the facility with diagnoses that included dementia, Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, cognitive decline, and behavioral changes due to the degeneration of nerve cells and brain tissue), and chronic pain. Resident #29 also had a history of falling and impaired skin integrity. An observation on 1/13/26 at 2:45 PM, revealed Resident #29 had multiple irregularly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview, and record review, the facility failed to ensure potentially hazardous foods were stored and labeled in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) expired foods were discarded; 2) foods were labeled and dated; and 3) foods were stored at safe temperatures in the Fireweed Cafe (Long-Term [LTC] Care Dining Room) refrigerators. These failed practices had the potential of causing or spreading foodborne illnesses to residents (based on a census of 73 out of 77) who received food from the kitchen Findings:An observation on 1/11/26 at 2:50 PM, of the Fireweed Cafe and the facility's hospital kitchen, revealed: 1) Dry Storage in Fireweed Cafe - Four Newman's Own French Dressing salad dressing packets, 1.5 ounces each, expired on 11/12/25. During an interview on 1/11/26 at 3:25 PM, the Food and Nutrition Manager (FNM) stated the packets were expired and should have been discarded. 2) Fireweed Cafe Freezer -One untied and torn…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-01-20 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on record review and interview, the facility failed to establish an accurate competency training program for travel Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) to ensure all travel nursing staff had the specific competencies and skill sets necessary to care for resident's needs as identified in the facility's facility assessment. This failed practice had the potential to place all residents (based on a census of 77) at risk of: 1) not having the necessary care and resources required for day-to-day operations (including nights and weekends) and emergencies; and 2) not receiving services that enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings:Review of the facility-provided Denali Center Facility Assessment 2026, dated 12/15/25, revealed: 1.Diseases/conditions, physical and cognitive disabilities treated in the organization: - Psychiatric/Mood Disorders. Impaired Cognition, Post-Traumatic Stress Disorder, Anxiety Disorder,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-20 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to provide a safe and sanitary environment. Specifically, the facility failed to: 1. Ensure enteral feeding equipment was properly labeled in accordance with infection prevention practices; and 2. Ensure clean linens were protected from environmental contamination during transport. These failed practices placed residents (based on a census of 77) at risk for the development of communicable diseases and/or infections. Findings:Enteral Feeding Equipment Labeling Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Traumatic Brain Injury (TBI), gastrostomy (A surgically created opening through the abdominal wall into the stomach used for the administration of nutrition, fluids, and medications directly into the gastrointestinal tract when oral intake is inadequate or not possible), and tracheostomy (A surgically…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-01-20 · tag F0699 — patternProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on record review and interview, the facility failed to ensure Long-Term Care (LTC) travel nursing staff (licensed nurses and certified nursing assistants [CNAs]) completed assigned trauma-informed care training. This failed practice placed 2 sampled residents (#'s 3 and 39), out of 18 sampled residents, and one unsampled resident (#66), with a documented trauma history, at risk of not receiving appropriate care for trauma-related needs. Findings:Record review on 1/11-15/26, revealed the facility-provided CMS-802 Matrix for Providers, completed on 1/12/26, revealed residents #'s 3, 39, and 66 were identified as being assessed as having a history of Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) and/or traumatic events in their life. During an interview on 1/14/26 at 2:57 PM, the Education Coordinator for the LTC stated trauma informed care training was assigned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure timely notification to the State's Senior Disability Services that a resident's stay would exceed 90 days and to request a Level II Preadmission Screening and Resident Review (PASRR - a federally required process to determine whether individuals with mental illness or intellectual disabilities need specialized services) evaluation for 1 resident (#3), out of 18 sampled residents. This failed practice delayed the required assessment and placed the resident at risk of not receiving necessary services and care to meet their individualized disability-specific needs. Findings:Record review on 1/11-15/26, revealed Resident #3 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), schizophrenia (a severe mental disorder characterized by delusions [false beliefs], hallucinations [perception of sights, sounds, etc. that are not actually present]), and post-traumatic stress disorder (PTSD - a mental health condition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure 1 resident (#29), out of 18 sampled residents, received treatment and care, in accordance with the professional standards of practice based on manufacture's recommendations. Specifically, the facility failed to use an appropriately sized lift sling while using a mechanical lift (a device designed to assist in the safe lifting and transferring a resident with limited mobility) during transfer. This failed practice placed the resident at risk for discomfort/pain during a transfer which had the potential to negatively impact the resident's physical health and/or psychosocial well-being. Findings:Record review from 1/11-15/26, revealed Resident #29 was admitted to the facility with diagnoses that included dementia, Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, cognitive decline, and behavioral changes due to the degeneration of nerve cells and brain tissue), and chronic pain. Resident #29 also had a history of falling and impaired skin integrity. An observation on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility's provider failed to: 1) write, sign, and date progress notes at each visit; and 2) review the residents total program of care, including treatment for a burn, at each visit for 1 resident (#29), out of 18 sampled residents. This failed practice resulted in inconsistent medical record documentation which placed the resident at risk of diminished continuity of care. Findings:Record review from 1/11-15/26 revealed Resident #29 was admitted to the facility with diagnoses that included dementia, Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, cognitive decline, and behavioral changes due to the degeneration of nerve cells and brain tissue), and chronic pain. While at the facility, the resident acquired a second degree burn on the left flank (lower to mid left side of back). An observation on 1/13/26 at 2:45 PM, revealed Resident #29 had multiple irregularly shaped red areas of skin on his/her left flank. The red patches of skin were of varying sizes and degrees of redness. The largest area was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on record review and interview, the facility's pharmacy services failed to ensure medication administration orders were accurate to meet resident needs for 2 residents (#'s 29 and 53), out of 18 sampled residents. This failed practice, of potentially having medications administered incorrectly, placed the residents at risk of choking and/or aspiration which could affect their overall health and wellbeing. Findings:Resident #29 Record review on 1/11-15/26, revealed Resident #29 was admitted to the facility with diagnoses that included Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, cognitive decline, and behavioral changes due to the degeneration of nerve cells and brain tissue), dementia, and chronic pain. During an observation and concurrent interview on 1/13/26 at 9:01 AM, Licensed Nurse (LN) #4 crushed and mixed the following medications in pudding for Resident #29: 1. Acetaminophen (a pain reliever) 325 MG (milligrams) oral tablet;2. Citalopram (an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure medication and medical supplies were labeled appropriately, and removed from service if expired, in 1 medication cart, out of 7 medication carts inspected, and 1 unit medical supply storage area, out of 3 unit medical supply storage areas inspected. These failed practices had the potential to place the residents of the Tamarack unit (based on a census of 24) at risk of receiving expired medications and supplies which could cause adverse reactions and/or complications. Findings:An observation on 1/14/26 at 9:40 AM, of the Tamarac Unit, revealed a medication cart which had the following: - Four Monoject Needless Med Prep Cannula, expired on 4/30/2025;- One BARD Powerloc Safety Infusion Set (needle to access ports) 20G (gauge) x 0.75 in (inches), expired on 1/19/25;- One 3M Tegaderm transparent film dressing 4 in x 4 3/4 in, expired on 1/31/25; - Two 3M Tegaderm transparent film dressing 2 3/8 in x 2 3/4 in, expired on 11/7/23;- One Replicare dressing 1 1/2 in x 2 1/2 in, expired on 7/28/23; and- One…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-10 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, observation and record review, the facility failed to ensure residents were provided with clear instructions on how to file a grievance while units were quarantined and segregated due to an Influenza outbreak, along with easy access to the grievance box during this time. This failed practice denied all residents and/or their representatives based on a census of 71, the right to submit grievances without fear of discrimination or reprisal. Findings: During a meeting with the Resident Council on 1/8/25 at 2:05 PM, when asked if they knew how to file a grievance, Resident #48 stated: there is one by the Administrator's office, the problem is that we are on full lockdown that started 10 days ago, and we are stuck in our wings [Units] so we cannot go get it, we cannot file a grievance. Resident #27, Resident #25 and Resident #51 also expressed confusion regarding the process of who handled the grievances and how to access the grievance forms and the grievance box. When asked if residents can…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Fcited before2025-01-10 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to properly store drugs and medical supplies. These failed practices had the potential to place all residents (based on a census of 71) at risk of receiving expired and non-sterile medications and supplies and subsequent adverse effects. Findings: Tamarack and [NAME] Medication Shared Room: An observation on 1/8/25 at 6:15 PM, revealed the following medical supplies were expired: - One box of 1.5 mL BD [[NAME], [NAME] and Company] ChloraPrep FREPP Clear applicators, expired on 10/24; - One quart bottle of Distilled [NAME] Vinegar in the ear irrigation tray, expired on 10/24. During an interview on 1/8/25 at 6:15 PM, Resident Care Coordinator (RCC) #3 confirmed expired supplies should have been discarded. Tamarack Medication Room: An observation on 1/8/25 at 6:28 PM, revealed the following medical supplies and medications were expired: - Two boxes of Nicotrol Inhaler 10 mg cartridges (smoking cessation aid), expired on 5/24; - One bottle of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review the facility failed to ensure potentially hazardous foods were stored, labeled and prepared foods in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) foods were labeled and dated; 2) expired foods were discarded; 3) Nutrition Services staff performed hand hygiene with glove changes and during the cooking and the preparation of foods. These failed practices had the potential of causing or spreading foodborne illnesses to residents, based on a census of 70, who received food from the kitchen. Findings: An observation, during the initial main kitchen tour, on 1/6/25 at 10:50 AM, revealed: 1) Dry Storage in Fireweed Café: - 30 expired Alpine Spiced Apple Cider Original- single serving packets- with manufacture best by date of 11/11/24; - 44 expired Kraft Sweet & Sour Sauce- 1- ounce single serve containers-with a manufacture used by date of 12/28/24; - One expired Kikkoman Less Sodium Soy Sauce-5-ounce…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-10 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure staff followed hand hygiene practices. Specifically, nutrition service staff did not performed hand hygiene and/or glove changes during the cooking and the preparation of the food. This failed practice placed all residents who receive food from the kitchen, based on a census of 70, at risk for cross contamination and spread of infectious disease; Findings: Dietary Hygiene: An observation on 1/9/25 at 7:43 AM, NS #1 was wearing gloves, while preparing supplemental shakes, pureed bananas, and was going in and out of the refrigerators. NS #1 changed his/her gloves without performing hand hygiene. An observation on 1/9/25 at 7:51 AM, NS #1 removed his/her gloves in the main kitchen, walked into the Fireweed dining room to retrieve supplies, returned and, without performing hand hygiene, and put on a new pair of gloves. During a continuous observation on 1/9/25 at 7:53 AM through 9:08 AM, NS #2 cooked and prepared food with gloved hands. NS #2 wiped his/her gloved hands on a towel placed next to steam table.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-10 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record review, the facility failed to ensure three residents (#s 19, 22, 25) out of 20 sampled residents were given the opportunity to make choices about aspects of their lives that were significant to them. Specifically, the facility failed to ensure residents' rights to choose and participate in activities consistent with his/her interest. This failed practice had the potential to affect residents' quality of life. Findings: Activities participation: An observation on 1/6/25 at 1:14 PM revealed a white board by the Activity Room, stated, January 6th, 2025. Happy New Year! No group activities today, sorry for inconvenience . Resident #19 Record review on 1/6-10/25, revealed Resident #19 was admitted to the facility with diagnoses that included morbid obesity (a complex chronic disease that is characterized by a Body Mass Index [BMI] of 40 or higher), major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), anxiety, and hemiplegia (neurological condition that involves paralysis of one side of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-10 · tag F0604 — failed to not use physical restraints improperly — patternEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview and observation, the facility failed to monitor, evaluate, and determine the use of assistive devices as physical restraints for two residents (#31and #61) out of 20 sampled residents. This failed practice placed residents at an increased risk for unnecessary physical restraints, inadequate monitoring of devices, and physical injury. Findings: Resident #31 Record review on 1/6-10/25, revealed Resident #31 was admitted to the facility with diagnoses that included dementia (a condition that affects memory and thinking) and Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination). During an observation and simultaneous interview on 1/7/25 at 11:56 AM, Resident #31 was wearing a belt around his/her waist that was attached to the wheelchair. In the center of the belt was a plastic piece that resembled a belt buckle. When resident was asked if he/she could remove the belt, he/she said no. Resident #31 further stated maintenance personnel or clinical staff were the only ones that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-10 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and observations, the facility failed to ensure activities of daily living (ADLs) were provided to two residents (#s 19 and 67), out of 20 sampled residents. Specifically, showers or baths were not provided to the residents as specified in their individualized plans of care. This failed practice resulted in residents not receiving ADLs to maintain personal care and hygiene . Findings: Resident #19 Record review on 1/6-10/25, revealed Resident #19 was admitted to the facility with diagnoses that included morbid obesity (a complex chronic disease characterized by a Body Mass Index [BMI] of 40 or higher), and hemiplegia (neurological condition that involves paralysis of one side of the body). Review of the facility's .Bath/Shower Schedule, dated 12/12/24, revealed Resident #19 was noted to have scheduled shower days on Tuesdays and Saturdays. During an interview on 1/6/25 at 11:15 AM, Licensed Nurse (LN) #2 stated the Bath/Shower schedule was the most recent version. During an interview on 1/6/25 at 11:20 AM, when asked if he/she was provided with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-10 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview the facility failed to obtain residents' consent for bedrails use and conduct accurate risks and benefits assessments for four residents (#'s 4, 8, 31 and 61) out of 20 sampled residents and one unsampled resident (#11) reviewed for bedrails use. This failed practice had the potential to place residents at risk of falls, entrapment, and other preventable accidents and potentially place residents at risk of feelings of isolation and helplessness . Findings: Resident #4 Record review on 1/6-10/25, revealed Resident #4 was admitted to the facility with diagnosis that included cerebral palsy (congenital disorder of movement, muscle tone, or posture). During an observation and simultaneous interview on 1/7/25 at 11:12 AM, Resident #4 had right upper extremity (RUE) contractions. Resident #4's bed had both upper side rails, and the right lower side rail raised. The raised and uncovered upper bed rails began at the top of the bed and ended by Resident #4's lower chest and the raised right lower side rail began at his/her right hip and ended…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide resident care with respect and dignity for two residents (#'s 27 and 50), out of 20 sampled residents. This failure placed the residents at risk of negatively affect the resident's quality of life. Findings: Resident #50 Resident #50 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease) and cerebrovascular accident (stroke). During an interview on 1/6/25 at 2:06 PM, Resident #50 stated he/she requested an evening snack a couple weeks ago. Resident #50 further stated, a CNA [Certified Nurse Assistant - unknown] told me to get up and get my own damn self to get ice cream and cookies. Resident #50 stated the CNA refused to get the snack for him/her. Resident #50 stated his/her nurse noticed him/her trying to get his/her own evening snack and asked what he/she was doing. Resident #50 told the nurse what the CNA said. Afterwards, the nurse brought him/her the requested ice cream and cookies. Resident #50 further stated he/she felt the comments made by the CNA made him/her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to implement written polices and procedures that prohibited and prevented mistreatment of residents, investigation, and reporting for 1 resident (#50) out of 20 sampled residents. Specifically, the facility failed to report an allegation of mistreatment to the Administrator within 24 hours if the events that cause the allegation do not involve abuse. This failed practice placed Resident#50 at risk of further exposure to mistreatment and/or mental anguish. Findings: Record review on 1/6-10/24, revealed Resident #50 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease) and cerebrovascular accident (stroke). Resident #50 BIMS (Brief Interview for Mental Status) test score was 14 (which indicated intact cognitive status). During an interview on 1/6/25 at 2:06 PM, Resident #50 stated he/she requested an evening snack a couple weeks ago. Resident #50 further stated, a CNA [Certified Nurse Assistant] told me to get up my own damn self to get ice cream and cookies. Resident #50 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to: 1) investigate an alleged report of mistreatment; 2) prevent further potential mistreatment once the allegation was made; and 3) report the allegation, by submitting the results of the investigation to the State Agency, administrator, or his or her designated representative within 5 working days, for 1 resident (#50), out of 20 sampled residents This failed practice placed Resident #50 at risk of further exposure to mistreatment and/or mental anguish. Findings: Record review on 1/6-10/25, revealed Resident #50 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease) and cerebrovascular accident (stroke). Resident #50 BIMS (Brief Interview for Mental Status) test score was 14 (which indicated intact cognitive status). During an interview on 1/6/25 at 2:06 PM, Resident #50 stated he/she requested an evening snack a couple weeks ago. Resident #50 further stated, a CNA [Certified nurse Assistant-unknown] told me to get up my own damn self to get ice cream and cookies. Resident #50…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure the comprehensive care plan reflected the current status and care for one resident (#31) out of two sampled residents with assistive seat belt devices. This failed practice placed the resident at risk for not receiving adequate care and increased risk for injuries. Findings: Record review on 1/6-10/25, revealed Resident #31 was admitted to the facility with diagnoses that included dementia (a condition that affects memory and thinking) and Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination). Review of the facility's Quarterly Assessment, dated 12/2/24, revealed: . Other: tremors . Mobility Braden: Very limited . Can resident appropriately call for assistance?: Yes . Morse Mental Status . Orientated to own ability . Does the resident have a hx [history] of falls?: Yes . Is resident able to communicate needs?: Yes . Free of restraints . Minimum Data Set (MDS -a federally required nursing assessment) Review: Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an accurate medical record was maintained for one resident (#10) out of 20 sampled residents. Specifically, the facility's medical record process failed to ensure medical records were accurate. This failed practice created incomplete medical records which placed the resident at risk for inconsistencies in treatment and care provided. Findings: Record review from 1/6-10/25 revealed Resident #10 was admitted to the facility with diagnoses that include generalized anxiety disorder, heart failure, and chronic kidney disease. Review of the facility's Medical Director's progress note, dated 1/1/25 at 5:16 PM, revealed: [Resident #10] suffers from bi-polar [mental health condition characterized by extreme mood swings including periods of elevated and irritable to low mood and energy levels], hallucinations, anxiety, and depression . Review of the facility's Medical Director's annual history and physical, dated 7/27/24 at 12:08 PM, revealed: [Resident #10] has a history of bipolar disorder with auditory hallucinations. We…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to adhere to facility's standards of care expectations, in the form of regular resident location and safety checks (called walking rounds), for 1 resident (#14), out of 4 residents reviewed. This failed practice resulted in the staff not being aware of the resident's elopement from the facility for an extended period, causing a delay in action to locate, which placed the resident at an increased risk for injury and accidents. Findings: Record review on 6/28/24 revealed Resident #14 was admitted to the facility with diagnoses that included dementia, cardiovascular accident with hemiplegia (weakness or paralysis of one side of the body) effecting the right side, and seizures. Resident #14 had a chronic history of alcohol use and had a history of repeated attempts to leave the facility seeking alcohol. Due to these repeated attempts, Resident #14 was placed with a wander guard device (a safety assistance device placed on a resident at risk for wandering and possible elopement. This device would trigger an alarm at any exit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-19 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to notify the Resident Representative (a Public Guardian) and the Office of the State Long-Term Care (LTC) Ombudsman, in writing, of a facility-initiated transfer or discharge for one resident (#1), out of one resident discharge reviewed. Specifically, the facility failed to: 1) Provide the Public Guardian in writing the intent to transfer/discharge the resident that included: The reason for transfer or discharge; the effective date of transfer or discharge; and information regarding: a) a statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such requests, and how to obtain an appeal form and assistance in completing the form; b) the name, address, and telephone number of the Office of the LTC Ombudsman; c) the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-06-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure: 1) Food was stored under proper sanitation and food handling practices in the main hospital kitchen; and 2) Hair nets were worn properly by food service workers assembling food in the kitchen in the Long Term Care (LTC) Center. These failed practices had the potential of causing or spreading food borne illness to all residents who utilized the kitchen services, based on a census of 72 residents. Findings: 1) Food Storage in Main Kitchen An observation of the walk-in refrigerator on 6/26/23 at 12:15 PM, revealed unlabeled, opened brats (sausages) not completely covered with plastic wrap. There were approximately 15 brats in each container. During an interview on 6/26/23 at 12:15 PM, the Dietary Manager stated that the brats were expired, weren't labeled correctly, and should have been thrown away. 2) Hair nets worn improperly An observation on 6/28/23 at 11:40 AM revealed the Food Service Supervisor and Food Service Worker #1 assembling food onto the resident dining trays on the food tray assembly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview, the facility failed to ensure acceptable professional standards of infection control. Specifically, the facility failed to wear gloves when working with PICC (peripherally inserted central catheter) lines (during flushes and medication administration) for 2 Residents (#'s 65 and 68) out of 2 residents with PICC lines. This failed practice had the potential of spreading infectious disease. Findings: Record review on 6/26-30/23 revealed Resident #65 was admitted to the facility with diagnoses that included hypertension. An observation on 6/26/23 at 3:00 PM, revealed Licensed Nurse (LN) #4 disconnected and flushed Resident #65's PICC line and did not wear gloves during the intervention. Record review on 6/26-30/23 revealed Resident #68 was admitted to the facility with diagnoses that included cachexia (loss of body weight and muscle mass leading to weakness) and diabetes. Review of Resident #68's physician order, dated 6/15/23, revealed ceftriaxone (an antibiotic) 2 milligrams in 50 milliliters IVPB (intravenous piggyback) for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-30 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure influenza immunization documentation (administered or declined) was completed for 1 resident (#59) of 5 residents sampled for influenza immunization. This failed practice denied the residents the opportunity to accept or decline the immunization and to receive education on the benefits and potential side effects. Findings: Record review on 6/26-30/23 revealed Resident #59 was admitted to the facility with diagnoses that included hypertension and COPD (chronic obstructive pulmonary disease- a progressive lung disease that causes airflow limitation). During an interview on 6/29/23 at 4:33 PM, the Administrator (AD) and Dispensing Pharmacist (DP) #1 were unable to locate documentation of the immunization being administered or refused for Resident #59. The AD and DP further stated that as evidenced by VacTrAK (a database of state recorded vaccinations) Resident #59 had not received an influenza immunization prior to admission to the facility. Review of the CDC (Centers for Disease Control and Prevention) website at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-06-30 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to ensure complete and current survey results and plans of correction were readily available to the residents, family members and resident representatives. This failed practice denied the residents and their family members or representatives (based on a census of 72) the right to be informed of previous survey results and the facility's plans for correction. Findings: Observation of the facility from 6/26-30/23 revealed a plastic sheet protector thumbtacked to a bulletin board located in the main common area that was labeled, State Survey Plan of Correction. The opening on top of the plastic sheet protector was approximately 58 inches from the floor. It held pages 1 and 7 from the 2021 state survey, 6 pages from 2020 state survey, and all of 2019's state survey. No state survey results from 2022 were present. During an interview on 6/29/23 at 4:49 PM, the Administrator, after reviewing the contents of the postings, stated the state survey copies should have been kept up to date. During an interview on 06/30/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-06-30 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to post the daily total number and the actual hours worked by Certified Nurse Aides (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). The failure to ensure accurate data was posted denied the residents and/or resident advocates information about staffing and the facility's ability to provide care to all residents residing in the facility (based on a census of 72). Findings: Observation of the facility from 6/26-30/23 revealed the Denali Center Assignment Sheet was taped to the main nurses' station located in the common area. The sheet contained the date, resident census, and listed the hallway unit staff assignments by shift. Further review of the posting revealed the total number and actual work hours of the nursing staff per shift was not documented. During an interview on 6/29/23 at 4:49 PM, the Administrator presented the Denali Center Assignment Sheet when asked where the nurse staffing information was posted. The Administrator further explained the posting included staff names that were scheduled, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$10,358 in federal fines across 1 penalty.
- $10,358 — penalty dated 2026-01-20
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FOUNDATION HEALTH LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2017 |
| GREATER FAIRBANKS COMMUNITY HOSPITAL FOUNDATION INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/2023 |
| BLAIS, KENDRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/20/2025 |
| EBENAL, SHELLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/20/2025 |
| MARTIN, SARAH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2017 |
| SUDDUTH, ANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/24/2023 |
CMS files one row per role, so the 9 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in AK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Alaska Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner. The starred figure is the national median (no state figure published).
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 025020. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.