Utuqqanaat Inaat
436 Mission Street, Kotzebue, AK 99752 · Non profit - Corporation · 18 certified beds · (907) 442-3321 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (17) — 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
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (74%) runs well above the national median (45%)
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 3 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
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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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 held steady at 5 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 | 26.2% | 16.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 5.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 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 | 13.8% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 29.7% | 19.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 3.1% | 14.7% | 18.9% | better |
| Long-stay residents with pressure ulcers | 0.0% | 6.9% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 17.0% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 34.6% | 18.8% | 17.1% | worse |
* 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.
§ 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.
Staffing
How full it usually is: this home is certified for 18 beds and averages 17.0 residents a day — about 94% occupied, or roughly 1 bed typically open. It runs fairly full. 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 7.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 5.12 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.
This home’s total nursing-staff turnover of 74% is well above 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.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · F2026-07-29 · tag F0563 — failed to protect the right to visitors — widespreadHonor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
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: 1) Develop written policies and procedures regarding the visitation rights for residents to include procedures for safety restrictions or limitations; and 2) Implement reasonable safety restrictions or limitations against a visitor for 1 Resident (#4), out of 1 resident reviewed, when abuse by way of misappropriation of resident property was suspected. The facility's failure to establish procedures for implementing reasonable safety restrictions placed all 18 residents at risk for continued unrestricted access by visitors when concerns involving abuse, exploitation, coercion, criminal activity, disruptive behavior, or illegal substances were identified. The facility failed to implement measures to protect Resident #4 when abuse was suspected. Resident #4 was subjected to potential misappropriation of resident property causing the resident to not have money when needed, a bank overdraft, and seizure of a social security check by the bank causing 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 · F2026-07-29 · tag F0609 — failed to report abuse allegations — widespreadTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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: 1) Report an allegation of abuse to the State Agency as required under CFR 483.12(c)(1). Specifically, the facility did not report suspected misappropriation of resident property for 1 Resident (#4), out of 1 resident reviewed, when first identified in January 2026; and 2) Develop and implement an accurate reporting policy for allegations of abuse that aligned with regulatory requirements. Not reporting a concern for abuse in an appropriate and timely manner subjected Resident #4 to continued misappropriation of resident property and financial insecurity causing the resident to not have money when needed, a bank overdraft, and seizure of a social security check by the bank causing the resident to be without money in May 2026 and June 2026. Not having accurate reporting requirements within their policy placed all residents (based on a census of 18) at risk for exposure to abuse, neglect, exploitation, or mistreatment, including injuries of unknown…
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 · F2026-07-29 · tag F0628 — widespreadProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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: 1) provide 1 resident (#12), out of 1 resident reviewed, with a written notice of transfer/discharge at least 30 days prior to the transfer or discharge in a language and manner they understand to include the reason for the transfer or discharge and the resident's appeal rights, including information on how to obtain an appeal form and assistance with completing and submitting an appeal hearing request; 2) provide the resident's written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman (OLTCO) and to accurately report to the OLTCO where the resident discharged to; and 3) Develop and implement an accurate transfer/discharge policy regarding notification of transfer/discharge that aligned with regulatory requirements. This failed practice denied the resident his/her right to receive the notice and know of his/her right to understand and exercise the right to appeal the transfer or discharge decision. Findings:1)…
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 · D2026-07-29 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of 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 and interview, the facility failed to ensure 1 resident (#12), out of 1 resident reviewed for care planning, was afforded the opportunity to participate in the development and implementation of his/her person-centered plan of care. This failed practice deprived the resident of the opportunity to participate in care planning and provide input regarding his/her needs, goals, choices, and preferences. Findings:Record review on 7/23 - 29/26 revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, history of falling, primary hypertension (high blood pressure), hyperlipidemia (high cholesterol), urinary incontinence, anemia, benign prostatic hyperplasia (enlarged prostate), and lower back pain. Further review revealed Resident #12 was discharged from the facility on 2/27/26. Review of Resident #12's medical record revealed no admission paperwork to include: 1) consent for treatment; 2) admission Agreement; 3) Explanation of Charges; 4)…
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 · D2026-07-29 · tag F0572 — isolatedGive residents a notice of rights, rules, services and charges.
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 1 resident (#12), out of 1 resident reviewed, was informed, orally and in writing, of the resident's rights upon admission. The facility was unable to demonstrate that the resident received the required notice of resident rights and services or that receipt of the information was acknowledged in writing. This failed practice had the potential to affect Resident #12's awareness of the resident's rights and responsibilities during the stay in the facility. Findings:A review of the facility's admission packet (a packet of documents to review and/or sign upon admission) revealed the document Resident Rights and Facility Responsibilities, undated, which revealed: . Each resident has the right to be informed, both orally and in writing (including Braille) in a language that the resident understands of his/her rights and all the rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. Further review revealed the facility's admission packet contained a Resident Rights…
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 · D2026-07-29 · tag F0582 — isolatedGive 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 1 resident (#12), out of 1 Medicaid eligible resident reviewed, was informed in writing, at the time of admission or when the resident became eligible for Medicaid, of the items and services included under the State Medicaid plan for which the resident could not be charged and those items and services offered by the facility for which the resident could be charged, including the amount of those charges. This failed practice had the potential for Resident #12 to incur charges without being informed which items and services were covered under Medicaid and which items and services could result in out of pocket costs. Findings:A review of the facility's admission packet (a packet of documents to review and/or sign upon admission) revealed: 1) A Consent to Treat signature page which documented: This Consent to Treat is made between the following parties: Utuqqanaat Inaat and. Resident. The Facility shall admit and provide the services specified herein to the Resident until the date of the Resident's discharge. Additional…
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 · D2026-07-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on record review and interview, the facility failed to investigate an allegation of suspected financial abuse/exploitation involving 1 resident (#4), out of 1 resident reviewed, and failed to implement effective protective measures since January 2026 when concerns were first identified, and when allegations continued to occur unresolved. These failures allowed the suspected perpetrator continued access to Resident #4 and the resident's financial resources after facility leadership identified the concern. The facility's failure to investigate the allegation and implement effective protective measures allowed Friend #18 continued access to Resident #4 and his/her financial resources. Resident #4 subsequently experienced continued depletion of his/her personal funds, an overdrawn bank account, and loss of access to his/her Social Security payment when the bank applied the payment toward the delinquent balance. The financial losses interfered with Resident #4's ability to use his/her funds according to 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 · D2026-07-29 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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, interview, and observation, the facility failed to implement an effective discharge planning process for 1 Resident (#12), out of 1 resident discharge reviewed, to include documentation of: 1) ongoing discharge planning goals throughout the resident's admission to include: a) identification of discharge needs and the development of a discharge plan; b) regular re-evaluation for need of possible modifications of the discharge plan; c) involvement of the interdisciplinary team in the ongoing process of developing the discharge plan; d) involvement of the resident in the development plan; and e) addressing the resident's goals of care and treatment preferences at discharge; 2) the basis and reason for discharge; and 3) sufficient preparation and orientation to ensure safe and orderly discharge. These failed practices resulted in Resident #12 leaving the facility without an established safe destination or adequate preparation to meet his/her ongoing care needs. Following discharge, Resident…
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 before2026-07-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on record review and interview, the facility failed to develop and/or implement a comprehensive person-centered care plan for 1 Resident (#12), out of 6 sampled residents, that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, the facility failed to develop a care plan that accurately reflected the resident's functional abilities and need for assistance with ADLs (Activities of Daily Living - basic self-care tasks essential for maintaining personal health and independence). This failed practice placed Resident #12 at risk for receiving insufficient assistance with ADLs, transfers, and mobility despite assessed functional limitations and a history of falls. Findings:Resident #12 Record review on 7/23-29/26 revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included low back pain, major depressive disorder, history of falling, and unspecified…
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 before2025-11-13 · 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 record review, observation, and interview, the facility failed to ensure staff followed accepted standards of practice for hand hygiene for 5 residents (#'s 5, 8, 11, 14, and 15), out of 5 residents observed. Specifically, staff failed to perform hand hygiene during personal cares and medication administration. This failed practice had the potential to place all residents at risk of contamination and transmission of infections.Findings: Resident #5 Record review on 9/22-26/25 revealed Resident #5 was admitted to the facility with diagnoses that included Type 2 Diabetes Mellitus (non-insulin-dependent diabetes). An observation on 9/23/25 at 12:55 PM, revealed Licensed Nurse (LN) #2 prepared Resident #5's insulin injection at the medication cart wearing gloves. LN #2 walked over to Resident #5 and offered him/her the medication. Resident #5 agreed and LN #2 pushed him/her in his/her wheelchair to his/her room wearing the same gloves. Without changing gloves or performing hand hygiene, LN #2 cleansed an area on Resident #5's abdomen with an alcohol wipe and administered 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 7 citations
- Potential for harm · E2025-11-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on record review, interview, and observation, the facility failed to ensure that 3 Residents (#'s 2, 4, and 15), of 8 sampled residents, received adequate supervision to prevent falls. This failed practice placed these residents at risk for injury, impaired mobility, pain, and reduced well-being. Findings: Resident #2 Record review on 9/22-26/25 revealed Resident #2 was admitted with diagnoses that included cerebrovascular accident (CVA - also known as stroke, when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel). Further review revealed that Resident #2 had multiple falls: 6/25/25, 7/29/25, and 9/20/25. The fall that occurred on 9/20/25 resulted in a major injury. Review of Resident #2's care plans, dated 6/24/25 and 9/23/25, revealed: . [Resident #2] has limited physical mobility. AMBULATION: The resident uses rolling walker for walking . LOCOMOTION: [Resident] uses rollator for locomotion . Review of Resident #2's care plan, last review completed 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 · E2024-04-25 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 record review, observation, and interview, the facility failed to ensure insulin (a medication for blood sugar maintenance) orders were followed for 2 residents (#5 and #10), out of 3 residents reviewed who received insulin. Specifically, the insulin orders were written to be administered before meals, and the insulin was administered after meals. This failed practice placed these residents at risk for experiencing potential adverse effects for not receiving insulin per the physician's orders. Findings: Resident #5: Resident #5 was admitted with diagnoses that included Type 2 Diabetes Mellitus with unspecified complications and essential hypertension (high blood pressure). Record review on 4/22/24 of Resident #5's insulin order, dated 2/14/24, revealed: Novolog Flex Pen [insulin] Subcutaneous [injection under the skin] Solution Pen-Injector 100 unit/ml [milliliter] (insulin aspart). Inject 8 unit subcutaneously before meals related to Type 2 Diabetes Mellitus with unspecified complications . (This medication is a rapid-acting anti-diabetic medication to help regulate blood…
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 · D2024-04-25 · 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 ensure a copy of 2 residents' (#8 and #12) transfer notices were 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 17, 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: Resident #8: Record review from 4/22-25/24 revealed Resident #8 was admitted to the facility with diagnoses that included dementia, epilepsy, stroke, and a history of falls. Further review revealed Resident #8 was hospitalized and discharged from the facility on 12/12/23 with a return anticipated and readmitted on [DATE]; discharged and hospitalized on [DATE] with a return anticipated and readmitted 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 · Dcited before2024-04-25 · 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 and interview, the facility failed to ensure a comprehensive care plan was developed and implemented with specific medical care needs for 1 resident (#8), out of 9 sampled residents. Specially, the facility failed to address risk factors or include specific information concerning the resident's prescribed anti-platelet medication (that inhibits the ability of platelets to clump together as part of a blood clot and could cause the risk of bleeding) in the resident's care plan. This failed practice had the potential to place the resident at risk for inconsistent care that could result from the many risk factors of the anti-platelet medication. Findings: Record review from 4/22-25/24 revealed Resident #8 was admitted to the facility with diagnoses that included dementia, epilepsy, stroke, and anemia. Further review revealed the resident had a history of falls. Review of Resident #8's Skin/Wound Note, dated 12/10/23, revealed: When Elder came to lunch, noticed left eye to be black and swollen. Palpated [felt] eye and around eye, Elder denies any pain or…
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 · D2023-02-02 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 MDS (Minimum Data Set-a Federally required assessment) was coded accurately for 2 residents (#s 4 and 12), out of 9 sampled residents, and 1 resident (#19), out of 2 closed record reviews. The failure to ensure the MDS was accurately coded placed the residents at risk for ineffective care planning. Findings: Diagnosis miscoding: Record review on 1/30/23-2/2/23 revealed both Resident #'s 4 and 12 were admitted to the facility with diagnoses that included dementia. Review of Resident #4's MDS assessment, a quarterly assessment dated [DATE], revealed the resident's dementia diagnosis was not coded. Further review of the resident's previous MDS assessments, dated 9/6/22 and 6/6/22, revealed the dementia diagnosis was coded. Review of Resident #12's MDS assessment, a quarterly assessment dated [DATE], revealed the resident's dementia diagnosis was not coded. Further review of the resident's previous MDS assessments, dated 9/19/22 and 6/19/22,…
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 before2023-02-02 · 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 and interview, the facility failed to ensure comprehensive care plans were individualized for 1 resident (#13), out of 9 sampled residents. This failed practice placed the resident at risk for not receiving the necessary care and services to address his/her individual needs. Findings: Record review on 1/30/23-2/2/23 revealed Resident #13 was admitted to the facility with diagnoses that included adult failure to thrive and chronic kidney disease. During an interview on 1/31/23 at 11:30 AM, Resident #13 stated he/she asked the staff for water when he/she was thirsty because the staff watched how much fluid he/she drank. Review of Resident #13's current comprehensive care plan, revised on 12/3/22, revealed: Encourage fluids during the day to promote prompted voiding responses. Review of the Resident's current physician orders revealed an order for a 2 Liter Fluid restriction [related to] hyponatremia [low blood sodium levels] with a start date of 4/29/22. During an interview on 2/1/23 at 4:07 PM, Licensed Nurse (LN) #1 stated Resident #13 was on a fluid…
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 before2023-02-02 · 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 observation, interview, and policy review, the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to ensure staff removed soiled gloves and performed hand hygiene after completing dirty tasks to clean tasks. This failed practice had the potential to affect all residents, based on a census of 17, for risk of the spread of infectious disease. Findings: An observation on 2/1/23 at 9:38 AM revealed Certified Nurse Assistant (CNA) #s 2 and 3 assisted Resident #10 to use the bathroom. Both CNAs wore gloves. CNA #2 was assisting the resident on one side to hold onto the handrail, while CNA #3 prepared the wet wipes. CNA #2 assisted the resident to a standing position after Resident #10 had a bowel movement. CNA #3 wiped the resident's anal area with wet wipes three times and discarded the soiled wipes in the trash can. CNA #3, while still wearing the soiled gloves, pulled Resident #10's brief and pants up, fixed the resident's jacket, and touched one of the handles of the wheelchair. Further observation revealed CNA…
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 | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 100% 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 2023. 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, FY2023). 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 2026-09-01 — CMS provider number 025035. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-13, 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.