Alaska Gardens Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Alaska Gardens Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF692Mar 19, 2025

  Based on observation, interview, and record review the facility failed to ensure residents received care and services to maintain acceptable parameters of nutritional status and there was a safe and accurate system to prevent complications from enteral (feedings administered through a tube) feedings for 12 of 12 residents (Residents 8, 19, 20, 22, 33, 21, 18, 26, 24, 14, 31 & 40) reviewed for nutrition and hydration. The failure to: accurately assess (and re-assess as needed) residents nutritional status and develop/revise/implement person-centered care plans (CP) for residents at risk; reconcile, accurately transcribe, and implement nutrition related physician orders and/or Registered Dietician (RD) recommendations; ensure timely RD evaluations; ensure residents were weighed according to… […]

• Immediate jeopardy, isolatedF678Oct 9, 2025

  Based on observation, interview, and record review, the facility failed to have a system in place that ensured basic life support was initiated immediately, as directed in the facility policy, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) when 1 of 1 resident (Residents 1) was reviewed for unexpected death in the facility. The facility failed to maintain the required unexpired supplies & equipment on the crash carts ready for immediate use and failed to maintain accurate Physician Orders for Life-Sustaining Treatment (POLST) data for immediate accessibility. […]

• Actual harm, isolatedF689Apr 29, 2025

  Based on interviews and record review, the facility failed to provid the supervision of two staff for bed mobility assistance per the plan of care for 1 of 5 sampled residents (Resident 1) reviewed for falls with injury. Resident 1 experienced harm when they received bed mobility assistance from one staff member, fell out of the bed and broke their arm. Findings included . Review of the electronic health records showed Resident 1 admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidney disease) and diabetes and was receiving dialysis (when waste in the blood is filtered through a machine). […]

• Actual harm, isolatedF689Mar 19, 2025

  Based on observation, interview, and record review the facility failed to develop and implement a resident-centered fall prevention care plan (CP) to reduce their specific risk factors for falls, consistently provide adequate supervision, and ensure residents were consistently monitored for post-fall injuries for 3 of 6 Residents (Residents 1, 8, & 11) reviewed for falls. Resident 1 experienced harm when they fell out of their wheelchair at the nurse's station and sustained a hip fracture. These failures placed all residents at risk for avoidable future falls, adverse events, physical injuries, pain, functional decline, and diminished quality of care/quality of life. […]

• Actual harm, isolatedF697Mar 19, 2025

  Based on interview and record review the facility failed to ensure residents were assessed and person-centered pain care plans (CPs) were developed/implemented and revised to meet their pain management needs for 3 of 5 sample residents (Residents 1, 2, & 13) reviewed for pain. Resident 2 experienced harm when the facility failed to accurately clarify and transcribe admission orders for pain medications, ensure scheduled pain medications were administered timely, evaluate for the underlying cause of sudden onset of severe chest pain after open heart surgery, monitor for adverse effects of opioid use, was transferred to the hospital in acute respiratory failure, and found to have broken chest wires (internal fixation hardware in place to hold the chest together after open heart surgery) that… […]