TACOMA, WA — A federal complaint investigation at Alaska Gardens Health and Rehabilitation uncovered significant deficiencies in the facility's nutritional care and monitoring practices, with inspectors determining that staff failed to ensure residents received adequate nutrition and that weight changes among vulnerable residents went unaddressed.
Facility Failed to Track Weight Loss in Tube-Feeding Residents
The inspection, completed on March 19, 2025, revealed that Alaska Gardens did not properly monitor residents who depended on tube feeding for their nutrition — a population that requires close and consistent oversight to prevent dangerous weight loss, dehydration, and electrolyte imbalances.
During the investigation, a staff member identified as Staff A told inspectors that during the facility's December 2024 and January 2025 Quality Assurance and Performance Improvement (QAPI) meetings, residents who had triggered alerts for significant weight changes were discussed and described as "consistent, monitored," with variance reports reportedly showing improvement.
However, when inspectors pressed further and asked whether the QAPI committee had identified any tube-feeding-dependent residents who experienced weight loss or hydration and electrolyte problems, Staff A acknowledged the committee had not.
This admission pointed to a critical gap: the facility's internal quality review process failed to flag nutritional decline in its most medically fragile residents — the very individuals the process is designed to protect.
Why Nutritional Monitoring in Nursing Homes Is Critical
Adequate nutrition and hydration are foundational to the health and recovery of nursing home residents, particularly those who cannot eat independently and rely on enteral (tube) feeding. When a facility fails to monitor these residents closely, the consequences can escalate rapidly.
Unintentional weight loss in elderly and medically compromised individuals is associated with a range of serious health outcomes. A loss of 5% or more of body weight over 30 days is considered clinically significant and can indicate underlying problems such as inadequate caloric intake, infection, or metabolic dysfunction. For tube-feeding-dependent residents, weight loss may signal that the feeding formula, rate, or schedule is not meeting the resident's metabolic needs.
Dehydration and electrolyte imbalances — conditions Staff A confirmed the QAPI committee had not screened for among tube-feeding residents — can lead to confusion, low blood pressure, kidney dysfunction, cardiac arrhythmias, and in severe cases, organ failure. Elderly individuals are particularly susceptible because their physiological reserves are already diminished.
Federal regulations under 42 CFR §483.25(g) require that nursing facilities ensure each resident maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible. This includes regular weight monitoring, caloric intake tracking, laboratory assessments of hydration and electrolyte levels, and timely adjustments to care plans when problems are identified.
QAPI Process Broke Down at Multiple Levels
The Quality Assurance and Performance Improvement program is a federally mandated system that requires nursing homes to identify problems proactively, analyze their root causes, and implement corrective actions. At Alaska Gardens, the QAPI process appears to have operated on the surface — meetings were held, reports were generated — but the committee failed to detect a fundamental care gap.
The inspection findings indicate that the facility did not self-identify its failure to ensure residents received the nutrition they required and that staff did not consistently monitor how residents responded to nutritional interventions. In practical terms, this means that even when care plans called for specific feeding protocols, the facility lacked a reliable system to verify those plans were working.
This type of systemic breakdown is particularly concerning because it suggests the problem was not limited to a single resident or a single staff error. Rather, it reflects an organizational failure in oversight — the kind of deficiency that can affect multiple residents simultaneously and persist undetected for extended periods.
What Should Have Happened
According to standard clinical protocols, tube-feeding residents should have their weight checked at minimum weekly during the first month of admission and at least monthly thereafter, with more frequent monitoring any time a weight change is detected. Laboratory values including serum albumin, prealbumin, and basic metabolic panels should be reviewed regularly to assess hydration and nutritional adequacy.
When a resident triggers a significant weight change alert, the care team is expected to conduct a comprehensive nutritional reassessment, adjust the feeding regimen as needed, and document both the intervention and the resident's response. The QAPI committee should then track these cases to ensure that corrective actions are producing results.
At Alaska Gardens, this chain of accountability broke down. The 64-page federal inspection report documented the deficiency under F-Tag 692, which governs the maintenance of nutrition and hydration status, and under F-Tag 867, which addresses the facility's QAPI program requirements.
The facility is required to submit a plan of correction to the Centers for Medicare & Medicaid Services outlining specific steps it will take to address the deficiencies and prevent recurrence. Residents and families seeking the full details of the inspection findings can access the complete report through the CMS Care Compare website or by contacting the Washington State Department of Social and Health Services.
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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