Wildflower Court
2000 Salmon Creek Lane, Juneau, AK 99801 · Government - City/county · 57 certified beds · (907) 463-8700 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 improved from 2 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 | 8.7% | 16.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.9% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 4.7% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.5% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.5% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.3% | 19.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.2% | 14.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 88.2% | 96.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 18.2% | 6.9% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.1% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.6% | 18.8% | 17.1% | better |
| 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 rehospitalized after admission | 17.0% | 15.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.4% | 11.0% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.46 | 1.00 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.22 | 1.36 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
33.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.0% 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 25 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 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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 | 33.8%CMS range 23.4–46.4 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.0–16.2 | 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 | 52.0% | 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 | 44.0% | 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 | 52.0% | 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 | 85.2% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.73 | 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 57 beds and averages 46.6 residents a day — about 82% occupied, or roughly 10 beds typically open. It usually has some room. 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 7.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 5.02 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 6.82 hrs/resident/day on weekends vs 7.39 on weekdays — 8% thinner on weekends. RN hours go from 1.81 to 1.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.
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.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · Fcited before2026-06-12 · 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, record review, and interview, the facility failed to store, prepare, and maintain food and food-contact sanitation in accordance with food safety standards. Specifically, the facility failed to ensure: 1) Sanitizer solutions used for food-contact surfaces were maintained at the manufacturer-recommended concentration; and 2) Food items available for resident use were labeled with required use-by dates and/or removed when expired; and 3) Culinary staff followed hand hygiene and glove-use practices to prevent cross-contamination during food preparation. These failed practices had the potential to cause cross contamination during food preparation and to allow contaminated and/or expired food to be served to 54 residents who received food from the kitchen, out of a total of 55 residents, placing these residents at risk for foodborne illness. Findings:.Sanitizer Concentration An observation on 6/10/26 at 10:39 AM, in the main kitchen, revealed two sanitizer buckets available for use. When tested…
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 · Ecited before2026-06-12 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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: 1. The Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, was completed with the required Quality Improvement Organization (QIO) name and toll-free telephone number before issuance for 3 residents (#18, #58, and #62), out of 3 residents who were reviewed for beneficiary notifications; and 2. The Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), Form CMS-10055, was provided when required for 1 resident (#18), out of 3 residents who were reviewed. Instead, the facility issued an expired Advance Beneficiary Notice of Non-Coverage (ABN), Form CMS-R-131, which was retired from use by CMS on [DATE]. These failed practices had the potential to prevent residents from receiving complete and accurate information regarding their Medicare appeal rights, including the right to request an expedited QIO review before termination of covered services, and could have limited their…
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 · Ecited before2026-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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, interview, and observation, the facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for 2 residents (#17 and #37), out of 4 residents reviewed for fall precautions. Specifically, the facility failed to: 1) Ensure adequate supervision and effective use of an assistive fall-prevention device for resident #37, who was found on the floor following an unwitnessed fall; and2) Ensure the Smart Caregiver sensor pad monitoring system used for Residents #17 and #37 were functioning properly and set at an audible volume to alert staff. These failures resulted in Resident #37 experiencing an unwitnessed fall and placed both residents at risk for delayed staff response, falls, and fall-related injury. Findings: 1) Adequate Supervision and Effective Use of Device Record review on 6/8-12/26, revealed Resident #37 was admitted to the facility with diagnoses that included unspecified dementia (cognitive decline and memory loss), age-related osteoporosis (brittle bones), history of transient ischemic attack (a temporary…
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 · D2026-06-12 · 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 record review, interview, and observation, the facility failed to ensure staff treated 1 resident (#39), of 14 sampled residents, with dignity and respect by honoring the resident's expressed preference for how staff announced themselves before entering the resident's room. Specifically, staff knocked on Resident #39's door despite the resident's known request that staff ring the mounted doorbell instead of knocking due to knocking being a trigger related to the resident's history of trauma and post-traumatic stress disorder (PTSD - a mental health condition that's caused by an extremely stressful or terrifying event). This failed practice had the potential to cause psychosocial harm by triggering trauma related symptoms, decreasing the resident's sense of safety, diminishing dignity, and reducing quality of life. Findings: Record review on 6/8-12/26 revealed Resident #39 was admitted to the facility with diagnoses that included PTSD and frontal lobe and executive function deficit (impaired cognitive functioning related to the area of the brain responsible for judgment,…
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 · D2026-06-12 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 complete all sections of the Resident Assessment Instrument 3.0 Minimum Data Set (MDS, a federally required nursing assessment for long term care residents) required to accurately make a comprehensive assessment for 1 Resident (#33), of 14 sampled residents. Specifically, the facility failed to complete Sections D (Mood), and E (Behavior) on both an annual and a quarterly MDS assessment, despite documentation in the medical record identifying mood concerns, refusal behaviors, and resident preferences. This failed practice had the potential to result in an inaccurate assessment of the resident's mood, behavioral, psychosocial, and care needs, placing the resident at risk for inconsistent or unmet care. Findings: Record review on 6/8-12/26, revealed Resident #33 was admitted to the facility with diagnoses that included a below the knee amputation of the right leg, heart failure, and hypothyroidism (a condition where the thyroid gland is underactive). Review of Resident #33's MDS Annual Comprehensive Assessment,…
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 · D2026-06-12 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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 follow the Preadmission Screening and Resident Review (PASRR) Level I determination and failed to notify the State of Alaska Division of Senior and Disability Services (SDS) when 1 resident (#61), out of 2 residents reviewed for PASRRs, compliance remained in the facility beyond the time-limited 90-day convalescent stay. This failed practice resulted in Resident #61 remaining in the facility without the required updated PASRR review and/or Level II evaluation to determine whether the resident required specialized services, which had the potential to adversely affect the resident's ability to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Findings: Record review on 6/8-12/26 revealed Resident #61 was admitted to the facility with diagnoses that included depression, borderline personality disorder (a mental health condition that affects emotional regulation), and chronic pain due to trauma. Review 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 · Dcited before2026-06-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop, implement, and revise the comprehensive person-centered care plan for 1 resident (#39) out of 14 sampled residents. Specifically, the facility failed to: 1) implement the care-planned fall prevention intervention of placing floor mats at the resident's bedside; and 2) include interventions for multiple high risk medications with fall-related side effects. These failed practices placed Resident #39 at risk for falls and fall-related injury, with the potential to negatively affect the resident's ability to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Findings: Record review on 6/8-12/26 revealed Resident #39 was admitted to the facility with diagnoses that included osteoarthritis (a degenerative joint disease), spinal stenosis (narrowing of the spinal cord), neurosarcoidosis (inflammatory disease of the central nervous system), obstructive sleep apnea (repeated interruptions of breathing during sleep), macular degeneration (eye disease that affects 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.
- Potential for harm · F2025-05-09 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 nursing staff have the specific competencies and skills set necessary to care for residents' needs. Specifically, the facility failed to ensure: 1) 6 Licensed Nurses (LN #'s 1, 2, 3, 4, 5, and 6), out of 15 LN personnel files reviewed, had current training for safe oxygen handling; and 2) 1 Certified Nurse Aide (CNA #1), out of 3 CNA personnel files reviewed, had a valid Cardiopulmonary resuscitation (CPR) certificate. This failed practice had the potential to place all residents (based on a census of 53) at risk of not receiving the necessary treatment and care and immediate assistance during an emergency. Findings: Oxygen Safety Education During an interview on [DATE] at 3:35 PM, during a review of personnel files, the Human Resources (HR) Manager stated LN #4 had no training for oxygen handling safety. During an interview on [DATE] at 4:33 PM, the Assistant Director of Nursing (ADON) stated oxygen safety education was required annually 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 · Fcited before2025-05-09 · 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 store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure: 1) expired food was discarded; and 2) the temperature of cooked potentially hazardous food was recorded after cooking. These failed practices had the potential of causing or spreading foodborne illness to all residents, based on a census of 53, who received food from the affected kitchens. Findings: Main Kitchen Observation on 5/5/25 at 10:55 AM, during the initial main kitchen tour with the Director of Nutrition Services (DNS), revealed: 1) Dry Storage: - One- 12-quart clear plastic container with a blue lid and a handwritten label that said, Brown Sugar 5-1-25 which contained two pieces of brown bread on top of the contents in the container. -Four- gallon size plastic bags which contained single servings of Smucker's Apple Butter not labeled with manufactures expiration or best used by date. -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 · E2025-05-09 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
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 that residents who received opioid pain medications (a class of strong pain-relieving medications that act on the nervous system, with potential for dependence, overdose, and serious side effects) were re-evaluated for pain for 11 residents (#1, #2, #6, #12, #20, #24, #26, #37, #49, #51, and #259), out of 53 residents reviewed for pain management. Specifically, the facility failed to re-evaluate the residents' pain level within 30 to 60 minutes following opioid administration. This failed practice had the potential to result in unrelieved pain, delayed identification of medication ineffectiveness, or overmedication. Findings: Resident #1 Record review on 5/5-9/25 revealed Resident #1 was admitted to the facility with diagnoses that included cerebral palsy (a group of neurological disorders that affect movement and muscle tone), hemiplegia (paralysis on one side of the body), and anxiety disorder. Review of Resident #1's Electronic Medication Administration Record (eMAR) and clinical progress notes revealed 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.
Show the remaining 19 citations
- Potential for harm · D2025-05-09 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 (#49), out of 5 residents observed for medication administration, was appropriately assessed for safe self-administration of medications. This failed practice placed the resident at risk of medication errors and adverse outcomes. Findings: Record review on 5/7/25 revealed Resident #49 was admitted to the facility with diagnoses that included cellulitis of the right lower limb (a bacterial skin infection causing redness, swelling, and pain), other chronic pain, and arthritis of the right knee due to other bacteria (inflammation of the joints that causes pain, stiffness, and swelling). An observation on 5/6/25 at 12:14 PM, revealed a medication cup containing two tablets of Tylenol sitting on Resident #49's bedside table. Review of Resident #49's Electronic Medication Administration Record (EMAR), dated 5/6/25, revealed an entry which documented that two tablets of Tylenol were administered at 12:00 PM. During an interview on 5/6/25 at 12:29 PM, Resident #49 stated the nurses usually left…
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 before2025-05-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 care plan was implemented for 1 resident (#40), out of 14 sampled residents. Specifically, a Certified Nurse Aide (CNA #2) failed to follow Resident #40's care plan for basic care needs while assisting the resident out of bed to the toilet. This failed practice had the potential to injure the resident and negatively impact the resident's physical well-being. Findings: Record review during 5/5-9/25 revealed Resident #40 was admitted to the facility with diagnoses that included anoxic brain damage (a brain injury that occurs when the brain is deprived of oxygen), and other reduced mobility. The resident also used ankle-foot orthoses (AFOs, devices designed to support the foot and ankle) to help him/her stand and perform transfers. Review of Resident #40's Care Plan, with a start date of 4/15/25, revealed: Approach . TRANSFERS: I need 2 PEOPLE to assist with my transfers. Sara Steady and 2-person extensive assist . TOILETING: I need 2 PEOPLE to assist with my toileting for using the flush toilet . 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 before2025-05-09 · 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 (#40), out of 14 sampled residents received quality care. Specifically,1) a Certified Nurse Aide (CNA #2) failed to follow 2 person assist during a transfer and toileting as specified in the comprehensive care plan; 2) CNA #2 did not safely handle the resident during transfer; and 3) the internal doorway to Resident #40's room was obstructed. This failed practice had the potential to place the resident at risk of injury and negatively impact the resident's physical health and well-being. Findings: Record review during 5/5-9/25 revealed Resident #40 was admitted to the facility with diagnoses that included anoxic brain damage (a brain injury that occurs when the brain is deprived of oxygen), and other reduced mobility. The resident also used ankle-foot orthoses (AFOs, devices designed to support the foot and ankle) to help him/her stand and perform transfers. Review of Resident #40's Care Plan, with a start date of 4/15/25, revealed: Approach . TRANSFERS: I need 2 PEOPLE to assist with my…
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 before2025-05-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, and interview, the facility failed to ensure residents' environment remains free of accident hazards. Specifically, the facility failed to ensure: 1) resident's room internal entryway was not obstructed for 1 resident (#40), out of 14 sampled residents; and 2) 1 exit door, out of 11 possible exit doors, was secured to prevent elopement of 6 residents (#'s 9, 1, 14, 20, 34, and 41), out of 53 residents (total census) who were at risk of wandering. This failed practice: 1) placed the resident at risk of delay in timely assistance in his/her room in emergency situations; and 2) placed residents who wandered at risk for unsafe situations if they eloped from the facility. Findings: Blocked Doorway Record review during 5/5-9/25 revealed Resident #40 was admitted to the facility with diagnoses that included anoxic brain damage (a brain injury that occurs when the brain is deprived of oxygen), and other reduced mobility. An observation on 5/5/25 at 2:58 PM, when this surveyor…
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 · D2025-05-09 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 36%. 9 medication administration errors were identified, out of 25 opportunities, during medication administration observations. This failed practice placed the resident at risk for adverse medication effects. Findings: Record review on 5/7/25 revealed Resident #49 was admitted to the facility with diagnoses that included cellulitis of the right lower limb (a bacterial skin infection causing redness, swelling, and pain), other chronic pain, and arthritis of the right knee due to other bacteria (inflammation of the joints that causes pain, stiffness, and swelling). An observation on 5/7/25 at 9:00 AM, revealed Licensed Nurse(LN) #4 prepared and administered medications for Resident #49. LN #4 handed the resident a medication cup containing the following 9 medications: - Entresto (a medication used to treat heart failure) 49mg-51mg tablet; - Eliquis (a blood thinner used to reduce risk of stroke and blood clots) 5mg tablet; - Allopurinol (a medication…
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 · F2024-02-16 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide 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
Based on record review, observation, and interview, the facility's pharmacy services failed to meet the obligations of its contract agreement. Specifically, pharmacy services failed to: 1) provide accurate pharmaceutical services to assure the accurate dispensing of drugs; and 2) provide consultation on aspects of the provision of pharmacy services in the facility. These failed practices placed all residents (based on a census of 48) at risk for receiving improper pharmaceutical services and the potential for medication errors and/or adverse reactions. Findings: Record review of the facility's contract agreement between the facility and Pharmacy #1, the pharmacy services for the facility, dated 1/1/23, revealed the pharmacy would: . provide the clinical services of a Registered Pharmacist and supply prescriptions in conformance with Federal and State regulations and the need of Wildflower Court patients, particularly as follows .: 1) Clinical Pharmacy Services . A pharmacist will be available for consultation on any drug therapy for the Medical Director and nursing staff at 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 · F2024-02-16 · tag F0756 — failed to review each resident's drug regimen — widespreadEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility's pharmacy services failed to: 1) complete monthly drug regimen reviews (DRRs), from November 2023 to January 2024, by a licensed pharmacist for all residents (based on a census of 48); and 2) complete accurate DRRs for 2 residents (#'s 2 and 35), out of 14 sampled residents. This failed practice placed all residents (based on a census of 48) at risk for unnecessary medications, medication errors, and/or adverse reactions. Findings: Consistent Monthly DRRs Record review of the facility's contract agreement between the facility and Pharmacy #1, dated 1/1/23, revealed the pharmacy would: . provide the clinical services of a Registered Pharmacist and supply prescriptions in conformance with Federal and State regulations and the need of Wildflower Court patients, particularly as follows .: 1) Clinical Pharmacy Services . A pharmacist will review each patient's chart every month. The drug therapy will be evaluated for proper application and dosage for each patient. The review will be documented in the patient's record in accordance with…
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 · F2024-02-16 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
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 the mandatory submission of staffing information based on payroll based journal (PBJ) data was submitted for the Fiscal Year (FY) Quarter 4 2023 (July 1 - September 30, 2023). This failed practice potentially denied residents and/or representatives (based on a census of 48), and the public, accurate staffing data when accessing the Nursing Home Compare website. Findings: Review on 2/12-16/23 of the facility's PBJ Staffing Data Reported, FY Quarter 2023 (July 1 - September 30), revealed the facility failed to submit data for the Quarter and had a one star staffing rating due to the failure to submit the data. During an interview on 2/15/24 at 3:50 PM, the Accounting Officer Controller stated the facility had missed the deadline to send the PBJ data for July 1 - September 30, 2023 due to the [NAME]/Wildflower transition (the facility had a change of ownership). Review of the facility's policy Wildflower Court Reporting Direct Care Staffing…
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 · E2024-02-16 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
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 the resident's, or the resident representative's, right to be informed of the risks and benefits of proposed care of psychoactive medication (a medication that can alter perception, mood, or behavior) administration was documented for 2 residents (#'s 2 and 35), out of 14 sampled residents. This failed practice had the potential to violate the resident's, or resident representative's, right to be informed of treatment and treatment alternatives or treatment options and to choose the alternative or option he/she preferred. Findings: Resident #2 Record review on 2/12-16/24 revealed Resident #2 was admitted to the facility with diagnoses that included depressive disorder and restless leg syndrome (a condition characterized by a nearly irresistible urge to move the legs). A review of Resident #2's active medication orders revealed an order for Diazepam [Valium - an anti-anxiety medication, which can be used to treat muscle spasms] 5 mg [milligrams] PO [by mouth] every HS [nighttime]. Further review revealed this…
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 · Ecited before2024-02-16 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), form CMS-10055, and the Notice of Medicare Non-Coverage (NOMNC), form CMS-10123, were delivered to 2 Medicare part A residents (#s 44 and 66) or the resident representatives, out of 3 sampled Medicare Part A residents reviewed, in a timely manner. Specifically, the forms were delivered either the day of, or 1 day before, the end of Medicare Part A coverage. This failed practice denied the resident, or family, a timely opportunity to appeal a denial of Medicare coverage and placed the resident at risk for not receiving services. Findings: Resident #44 Review of the SNF Beneficiary Notification Review for Resident #44, that was filled out by the facility, revealed Resident #44's Medicare Part A Skilled Services Episode started on 10/9/23 and ended on 10/17/23. Review of Resident #44's SNFABN and NOMNC forms revealed these forms were signed on 10/17/23, the day the Medicare Part A services ended. Resident #66 Review of the SNF Beneficiary Notification…
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 · D2024-02-16 · 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
Based on record review and interview, the facility failed to ensure a copy of the resident's (#6) transfer notice was sent to the Office of the State Long Term Care (LTC) Ombudsman. This failed practice had the potential to affect all residents, based on a census of 48, by: 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges. Findings: Record review from 2/12-16/24 revealed Resident #6 was admitted to the facility with diagnoses that included stroke and expressive aphasia (the person knows what they want to say but is unable to produce the words or sentence). Further review revealed the resident suffered injuries after an unwitnessed fall in the facility and was hospitalized during the survey. During an interview on 2/15/24 at 2:35 PM, when asked about notifications when a resident was transferred to the hospital,…
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 before2024-02-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 implement the comprehensive person-centered care plan for 1 resident (#4), out of 14 sampled residents, to repair eyeglasses and ensure the resident had regular eye exams, for proper and ongoing assessments of a known eye condition. This failed practice had the potential to delay treatments to improve eyesight by not scheduling follow up appointments, which could have affected the resident's ability to maintain his/her highest practicable physical, mental, and psychological well-being. Findings: Record review on 2/12-16/24 revealed Resident #4 was admitted to the facility in 2005 with diagnoses that included a traumatic brain injury, seizures, and 3rd nerve palsy of the left eye (partial or complete paralysis of the 3rd cranial nerve, which could result in the eye positioned downward and outward with the inability to move the eye normally. Double vision, enlarged pupil, droopy eyelid, eye misalignment, and tilting head to compensate for abnormal eyesight could also occur). An observation on 2/13/24 at 9:31…
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 before2024-02-16 · 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, interview, and observation, the facility failed to ensure information about a new open area on the skin was communicated to the nurse for 1 resident (#34), out of 14 sampled residents. Specifically, the Certified Nursing Assistants (CNAs) failed to communicate to the nurse information about a new non-pressure related wound discovered on Resident #34's sacral area (area at the end of the spine in the pelvic region) during cares. This failed practice placed this resident at risk for further skin breakdown and infection. Findings: Record review from 2/12-16/24 revealed Resident #34 was admitted to the facility with diagnoses that included spinal stenosis (narrowing of the spaces around spinal cord); weakness; and cellulitis (deep infection of the skin). Further review revealed the resident was wheelchair bound. During an interview on 2/12/24 at 10:55 AM, Resident #34 stated his/her sacral area was sore, and the CNAs applied a barrier cream to prevent skin breakdown and repositioned him/her to get pressure off the sacral area while he/she was in bed. During 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 before2024-02-16 · 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, interview, and observation, the facility failed to ensure the sole resident who smoked at the facility (Resident #4), followed his/her care plan and the smoking policy. Specifically, the facility failed to ensure the resident smoked in the one and only designated smoking area on campus, where appropriate safety measures were maintained. This failed practice had the potential to introduce avoidable fire accidents, which could affect all residents (based on a census of 48). Findings: Record review on 2/12-16/24 revealed Resident #4 was the only resident who smoked. He/she was grandfathered in, allowed to continue to smoke, as he/she was admitted prior to 3/12/12. Review of Resident #4's medical record revealed Smoking Safety Evaluation forms that were completed 3/2/23 and 8/23/23. Both evaluations revealed Resident #4 was safe to smoke independently. Review of Resident #4's care plan, under activities, revealed: . I like to smoke on a daily basis, I am allowed to use the smoking shed outside of cranberry home . During an interview on 2/13/24 at 9:38 AM,…
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 · D2024-02-16 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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, observation, and interview, the facility failed to ensure significant weight loss was reported to the physician for 1 resident (#39), out of 14 sampled residents. This failed practice had the potential to place the resident at risk for further weight loss and complications due to excessive weight loss. Findings: Record review from 2/12-16/24 revealed Resident #39 was admitted to the facility with diagnoses that included stroke and seizures. Review of Resident #39's Physician Order, dated 9/20/23, revealed the resident was prescribed a regular textured diet. Review of Resident #39's weight history, dated 9/21/23 through 2/1/24, revealed a 16.59% weight loss since admission on [DATE]. The weight on 2/1/24 was recorded as 101.2 pounds which was a 20.5 lb. weight loss since 9/21/23. The record did not reveal any interventions or communications for the weight recorded on 2/1/24 of 101.2 lbs. Below are the recorded weights since 9/21/23: - 9/21/23 121.60 pounds (lbs.) - 10/13/23 115.5 lbs. -…
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 · D2024-02-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 the medication regimen for 1 resident (#35), out of 14 sampled residents, was free from an unnecessary medication. Specifically, the facility failed to ensure 4 different Morphine (a narcotic medication that helps control severe pain) as needed medication orders were written with specific parameters for each order. This failed practice placed the resident at risk of excessive medication administration, subtherapeutic (too low a dose to be effective) medication administration, and/or the potential for adverse reactions. Findings: Record review on 2/12-16/24 revealed Resident #35 was admitted to the facility with diagnoses that included dementia and anxiety. Further review revealed Resident #35 was on palliative care (specialized medical care for people with a serious illness, the focus is on providing relief from the symptoms of the illness to improve quality of life). Review of Resident #35's MDS (Minimum Data Set - a federally required assessment) admission assessment, dated 11/15/24, revealed Resident #35 had 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 · D2024-02-16 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to ensure 2 residents (#'s 7 and 24) out of 14 sampled residents, were provided with their ordered diet. Specifically, no oversight was provided to the staff serving the resident's meals in the unit kitchens. This failed practice had the potential to place the residents at risk for poor health outcomes, inadequate nutritional intake, and risk for medical complications. Findings: During the resident council meeting held on 2/14/24 at 10:32 PM, Resident #'s 2; 4; 5; 24; 34; 38; 42; 45; and 100 were in attendance. When asked about the food served in the facility, the consensus was there was too much sugar and too many carbohydrates being served. One resident stated the facility did not have any diabetic diets. Another resident stated the facility used meal (diet) cards, but he/she sometimes sent the food back, because the meal did not correspond to the meal card. Resident #7: During an observation on 2/14/23 at 12:21 PM, Home Attendant (HA) #1 was observed plating the resident's meals from the steam table on unit…
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 · D2024-02-16 · 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 staff performed hand hygiene according to accepted professional practices during provision of care and services for 1 resident (#148), out of 14 sampled residents. Specifically, hand hygiene was not performed when moving from a dirty to clean task during wound care. This failed practice had the potential to increase the risk for development and transmission of disease and infection in a vulnerable population. Findings: Record review from 2/12-16/24 revealed Resident #148 was admitted to the facility with diagnoses that included sepsis (a life-threatening complication of an infection) due to a urinary tract infection. Further review revealed the resident had a sacral wound/tear on admission. During an observation on 2/15/24 at 2:00 PM, Licensed Nurse (LN) #5 was performing wound care for Resident #148. The LN first removed the old dressing from the resident's sacral region. Without performing hand hygiene or glove change, LN #5 cleaned the resident's sacral area with normal saline soaked gauze. Next,…
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 · C2025-05-09 · tag F0678 — failed to provide CPR when needed — widespreadProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 1 Certified Nurse Aide (CNA #1), out of 3 CNAs personnel file reviewed, had Cardiopulmonary Resuscitation (CPR) certificate before providing direct patient care. This failed practice had the potential to place all residents (based on a census of 53) at risk of not receiving CPR immediately during an emergency. Findings: Review of facility personnel files on [DATE] at 3:35 PM, revealed the Human Resources (HR) Manager stated CNA #1 was hired on [DATE]. Further review revealed CNA #1's personnel file did not contain a CPR certificate. During an interview on [DATE] at 4:20 PM, the HR Manager confirmed that CNA #1 had no CPR certificate since hire. The HR Manager explained that the CNA was enrolled in the CPR class, but the CNA did not complete the course. The HR Manager also added that the Staff Development Office should have followed up with the completion of the course. During an interview on [DATE] at 4:27 PM, when asked if the CNA was allowed…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CITY AND BOROUGH OF JUNEAU ALASKA | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 07/10/2023 |
| DEERING, RICHELLE | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2024 |
| GEIGER, HAROLD (HAL) | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 07/10/2023 |
| JOHNSTON, DEBORAH | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 07/10/2023 |
| LETTERMAN, CHRISTOPHER | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 12/01/2024 |
| MALTER, ALEX | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| MERTZ, MAX | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 07/10/2023 |
| PETERSEN, LISA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 07/10/2023 |
| RASTER, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 07/10/2023 |
| SOLOMON-GROSS, KENNY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 07/10/2023 |
| TINGEY, BRENT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| BARTLETT REGIONAL HOSPITAL | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/29/2025 |
| KOELSCH, DEBORAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/24/2024 |
| LAWSON-CHURCHILL, TAMI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/10/2023 |
| MCDOWELL, KIM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/10/2023 |
| MOOREHEAD, GAIL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/10/2023 |
| WANNER, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/21/2024 |
CMS files one row per role, so the 23 rows in the source record cover these 17 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.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
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 025027. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-12, 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.