Based on observation, interview, and record review the facility administration failed to ensure effective and efficient use of resources to provide for resident safety and to ensure the highest practicable physical, mental, and psychosocial well-being of all residents, based on a census of 94. The facility administration failed to maintain the facility in substantial compliance with regulatory requirements which resulted in substandard quality of care in which residents experienced actual physical harm including development of Stage II, III, and IV pressure ulcers and psychosocial harm to residents affected by prolonged isolation and inadequate care to meet physical, social, and emotional needs due to staffing shortages and facility directed room-based care (RBC) (residents cannot leave… …
F835 citations in Alaska
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Alaska cites F835 more often than its own record predicts
4.74 times the share F835 takes of citations nationally.
Of every deficiency written in Alaska in 2024, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Alaska surveyors wrote
F835 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.
Based on interview, observation, and record review, the facility administration failed to ensure effective and efficient use of resources to provide for resident safety and to ensure the highest practicable physical, mental, and psychosocial well-being. This placed all residents (based on a census of 93) at risk for physical and/or psychosocial harm. The facility administration failed to maintain the facility in substantial compliance with regulatory requirements which resulted in substandard quality of care in which residents experienced actual physical harm including development of Stage III, IV, and unstageable pressure ulcers and deep tissue injuries. These failed practices caused actual harm due to the of deterioration of pressure ulcers. …
Based on interview and record review, the facility's administration failed to ensure training, competency, and documentation pertaining to behavioral health care was provided effectively and efficiently to ensure the highest practicable physical, mental, and psychosocial well-being of residents. This failed practice placed all residents (based on a census of 96) at risk for receiving less than optimal care in a safe environment. Findings: During an interview on 6/4/24 at approximately 3:00 PM, the facility's administrator informed the survey team that she was leaving the facility and verbalized the Director of Nursing (DON) would be assuming the responsibility for the remaining survey. …
What else Alaska surveyors cite →
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