Utuqqanaat Inaat

In the surveyor’s words

From the most serious findings on record at Utuqqanaat Inaat, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF563Jul 29, 2026

  .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. […]

• No harm, potential for more than minimal, widespreadF609Jul 29, 2026

  .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… […]

• No harm, potential for more than minimal, widespreadF628Jul 29, 2026

  .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… […]

• No harm, potential for more than minimal, widespreadF880Nov 13, 2025

  .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. […]

• No harm, potential for more than minimal, patternF689Nov 13, 2025

  .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. […]