Based on record review and interview, the facility failed to ensure direct care staff were provided appropriate competencies and skills sets to assure residents who express suicidal ideation (thoughts and/or plans to commit suicide) were safe. Specifically, the facility failed to: 1) provide training for knowledge of how to accurately perform a one-on-one observation; and 2) how to accurately document one-on-one observations for standard accountability. This failed practice placed all residents (based on a census of 96) at risk for improper or inconsistent one-on-one observation which could lead to self-harm, suicide attempt, or completed suicide. …
F741 citations in Alaska
Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Alaska cites F741 more often than its own record predicts
15.47 times the share F741 takes of citations nationally.
Of every deficiency written in Alaska in 2024, this is the portion that was F741.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Alaska surveyors wrote
F741 findings written in Alaska, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
What else Alaska surveyors cite →
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