TACOMA, WA - Federal inspectors documented ongoing medication management failures at Alaska Gardens Health and Rehabilitation during a March 2025 complaint investigation, finding the facility had not corrected previously cited medication errors despite implementing performance improvement projects.
Repeated Medication Administration Failures
Alaska Gardens Health and Rehabilitation continues to face challenges with medication management, particularly for newly admitted residents. The March 4, 2025 inspection revealed the facility had failed to ensure prescribed medications were readily available when residents arrived at the facility, creating potentially dangerous gaps in treatment.
The inspection report documented that respiratory medications, critical for residents with breathing conditions, were not consistently administered as prescribed. These medications, which include bronchodilators and corticosteroids, are essential for managing conditions like chronic obstructive pulmonary disease (COPD) and asthma. When these medications are delayed or missed, residents can experience difficulty breathing, decreased oxygen levels, and potentially life-threatening respiratory distress.
The facility's administrator acknowledged during the inspection that they had received a citation for significant medication errors just weeks earlier, on January 22, 2025. That citation specifically addressed the facility's failure to have medications available for administration. Despite alleging compliance by January 27, the March inspection found the problems persisted.
Admission Process Breakdowns
The inspection uncovered systemic issues with Alaska Gardens' admission procedures that directly contributed to medication errors. While the administrator reported developing a new admission checklist in response to previous citations, inspectors found this measure had not resolved the underlying problems.
When residents transfer from hospitals or other care settings to a nursing facility, medication continuity is crucial. Many residents arrive with complex medication regimens that must be maintained without interruption. Conditions such as diabetes, heart disease, and respiratory disorders require strict medication schedules. Even brief interruptions can lead to blood sugar spikes, cardiac events, or breathing emergencies.
The facility's Quality Assurance and Performance Improvement (QAPI) committee had initiated three separate Performance Improvement Projects following their January citations. However, inspectors determined these efforts had not adequately addressed the root causes of medication availability issues. The administrator confirmed to inspectors that medication errors related to availability remained an active concern.
Medical Reconciliation Failures
Beyond availability issues, the inspection revealed Alaska Gardens failed to ensure medication orders were "accurate, complete, and reconciled" for new admissions. Medication reconciliation is a critical safety process that involves verifying a resident's complete medication list, comparing it with new orders, and resolving any discrepancies.
Incomplete medication reconciliation can result in dangerous drug interactions, duplicate therapies, or missed essential treatments. For elderly residents who typically take multiple medications, these errors multiply risks exponentially. Common consequences include falls from unmanaged blood pressure medications, confusion from duplicate sedatives, or organ damage from incorrect dosages.
The respiratory medication failure cited in January 2025 exemplifies these risks. Respiratory medications often require precise timing and dosing to maintain stable breathing patterns. Missing even a single dose can trigger acute breathing difficulties, particularly for residents with advanced lung disease. These residents may require emergency interventions, including supplemental oxygen or hospital transfer, when their medication schedules are disrupted.
Industry Standards and Requirements
Federal regulations require nursing facilities to maintain a comprehensive medication management system that ensures all prescribed medications are available and administered correctly. This includes having protocols for obtaining medications before or immediately upon admission, maintaining accurate medication records, and conducting thorough reconciliation processes.
Standard practice dictates that facilities should obtain medication histories and current prescriptions before a resident's arrival whenever possible. For urgent admissions, facilities must have arrangements with pharmacies to obtain critical medications within hours, not days. Many facilities maintain emergency medication supplies or have 24-hour pharmacy services specifically to prevent treatment gaps.
The medication reconciliation process should involve multiple checkpoints: reviewing hospital discharge summaries, contacting previous providers, verifying with family members, and comparing all sources to create an accurate medication profile. This process typically requires coordination between nurses, pharmacists, and physicians to ensure nothing is missed or duplicated.
Additional Issues Identified
The inspection also noted concerns with the facility's quality assurance processes. Despite having an active QAPI committee and multiple improvement projects underway, the facility had not identified their systemic failures in the admission process until prompted by inspectors. This suggests potential gaps in their internal monitoring and self-assessment procedures.
The pattern of repeated violations, with the facility receiving citations in January and similar problems persisting through March, indicates that corrective actions were either inadequate or improperly implemented. The facility's assertion of compliance on January 27, 2025, proved premature given the ongoing issues documented six weeks later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alaska Gardens Health and Rehabilitation from 2025-03-19 including all violations, facility responses, and corrective action plans.
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