Cordova Community Med Ltc
CORDOVA COMMUNITY MED LTC in CORDOVA, AK — inspection on March 16, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Exhibit A of the Resident admission Agreement, revealed: - The daily rate includes. [a list of services and items provided].
Further review revealed no daily rate listed to show how much it cost to be in the facility per day. - Items no included in the daily rate include. [a list of services and items not covered in the daily rate].
Further review revealed no cost on items that could potentially have a flat rate, like hairdresser, transportation and escorts to appointments, rehabilitation services (physical therapy, occupational services, speech therapy), or x-rays.
During an interview on 3/11/26 at 2:43 PM, the Director of Nursing (DON) stated the daily rate was not listed in the admission packet for the residents to receive at admission and acknowledged the services that may incur charges did not have fees listed for those services that could be associated with a flat rate.
Review of the resident rights titled Your rights and Protections as a Nursing Home Resident, undated, revealed: .
Get Information on Services and Fees: You have the right to be told in writing about all nursing home services and fees (those that are charged and not charged to you) before you move into the nursing home and at any time when services and fees change.
025028 03/16/2026
Cordova Community Med Ltc 602 Chase Ave Cordova, AK 99574
Background clearance
State of AK Provisional Background, effective 2/12/25, revealed: Policy Statement.
Once a
and must comply with supervision and access restrictions until they receive final background check approval. If the position is the CEO, directors, department managers or doctor, these positions will not start in these positions until a fully approved clearance on the background checked is done.
Other employees can start employment when provisional background checked is completed so long as the hiring manager follows the policies outlined below.
Requirements for Provisional Employees.
Supervision 1.
Continuous Supervision- Provisional employees must be directly supervised by an employee with full background check clearance at all times. 2.
Restricted access- Provisional employees may not have unsupervised access to vulnerable patients, sensitive information, or high- security areas. 3.
Electronic Medical Records (EMRs)- Access to EMRs will be limited based on role and subject to approval by the Compliance and HR departments.
Responsibilities.
Human Resources (HR)- Tracks background checks status, ensures timely fingerprint submission, and notifies departments of expiring provisional statuses.
Department Supervisors- Ensure provisional employees are monitored, supervised, and do not exceed their 60-day provisional period.
Compliance & Security Teams- Restrict access to sensitive areas and systems as needed for provisional employees.
Review of the facility policy Abuse Prevention, Recognition and Reporting Under State Law and the Elder Justice Act, last reviewed 3/6/26, revealed: .
Screening: All candidates for employment to CCMC will be screened, by contacting the appropriate state licensing registry and/or the previous employer, to ensure that candidates have not been convicted of abusing, neglecting, or mistreating residents by a court of law. CCMC will refrain from employing any individual prohibited from working in a long term care facility because of failure to report a suspicion of a crime against a resident or a long term care facility.
Review of 7 AAC 10.900(b) at https://www.akleg.gov/basis/aac.asp#7.10.900, the 34th Legislature (2025-2026), revealed: .
Each individual who is to be associated with a provider in a manner described in this subsection must have a valid background check conducted under 7 AAC 10.900 - 7 AAC 10.990 if that individual is 16 years or older and will be associated with the provider as (1) an administrator or operator; (2) an individual service provider; (3) An employee, an independent contractor, an apprentice, an unsupervised volunteer, or a board member if that individual as (A) regular contact with recipients of services; (B) access to personal or financial records maintained by the provider regarding recipients of services, including access to (i) personal identifying information, financial information, treatment information, or medical records .(4) an officer, a director, a partner, a member, or a principal of the business organization that owns an entity, if that individual has (A) regular contact with recipients of services; (B) access to personal or financial records maintained by the provider regarding recipients of services, including access to (i) personal identifying information, financial information, treatment information, or medical records .
025028 03/16/2026
Cordova Community Med Ltc 602 Chase Ave Cordova, AK 99574
Review of Resident #1's quarterly MDS assessment, dated 12/20/25, revealed: [Section] J1800.
Has the resident had any falls since admission/entry or reentry or the prior assessment. whichever is more recent? 0 [No].
Review of Resident#1's ED Note, dated 10/7/25, revealed: [Resident #1] reports [he/she] was in [his/her] wheelchair tonight and leaned forward to pick up something. As [he/she] leaned, [he/she] slipped out of the wheelchair and landed on the floor, striking [his/her] left shoulder posteriorly on furniture as [he/she] fell.
During an interview on 3/10/26 at 2:40 PM, Resident #1 stated that in October 2025 he/she had reached over to pick up a colored pencil that was on the floor and then fell out of his/her wheelchair but that he/she had not fallen since then.
During an interview on 3/10/26 at 2:53 PM, the Assistant Director of Nursing (ADON) stated that she missed Resident #1's October fall during her review and that it should have been included in the 12/20/25 quarterly MDS assessment. Resident #3
Record review on 3/9-13/26 revealed Resident #3 was admitted to the facility with diagnoses that included Squamous cell carcinoma (a type of cancer) of skin of unspecified parts of face with an onset date of 11/7/25.
Review of Resident #3's quarterly MDS assessment, dated 2/2/26, revealed: [Section] M1040.
Other Ulcers, Wounds, and Skin Problems.
Check all that apply. Z.
None of the above were present [selected].
Review of Resident #3's Periodic Provider Assessment, dated 10/29/25 at 3:50 PM, revealed: . worsening R [right] temple lesion, s/p [status post] 5 FU [5- Fluoroucil, a medication used to treat cancer] injection with initial response and now worse.
Had consult with oncology and waiting for plan.
Injection will not cure but may slow progression.
Random observations on 3/9-13/26, revealed Resident #3 was seen with a wound dressing on the right side of his/her face covering an area including his/her right temple and portions of his/her right cheek.
During an interview on 3/11/26 at 8:43 AM, the ADON stated that Resident #1 did have a cancerous lesion on his/her face and that section M1040 box D of the 2/2/26 quarterly MDS assessment, Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion), should have been selected and that it was an oversight.
During an interview on 3/10/26 at 2:53 PM, the ADON stated that her responsibilities at the facility included updating the resident's MDS assessments and other tasks to support the Director of Nursing.
While updating the MDSs, she did a deep dive to review notes and progress notes in the resident's Electronic Medical Record (EMR) and spoke to floor staff about the residents.
She also attended care conferences which included staff members and residents and/or their representatives as needed to clear up any questions she may have while finalizing the MDS.
Review of the facility policy Minimum Data Set (MDS), last reviewed 6/27/25, revealed: .
Minimum Data Set (MDS): is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes.
The Care Area Assessment will include, but is not limited to, the look back period, staff and resident interviews, quarterly or comprehensive assessments, and medication, chart, and care plan review.
025028 03/16/2026
Cordova Community Med Ltc 602 Chase Ave Cordova, AK 99574
Review of Resident #3's SOCIAL HISTORY/ Trauma and Cultural Assessment, dated [DATE], revealed: . Is there a history of physical, emotional, or sexual abuse (if Yes reference in Care Plan for trauma needs.) Trauma- son died at age of 21 in a motorcycle wreck.
Resident had difficulty coping with loss.
Resident states 1st husband was untruthful.
Family describes a lot of arguing among her and spouse.
Significant Life Experiences.
Marital years. 1st marriage described as volatile.
During an interview on [DATE] at 10:44 AM, the Director of Nursing (DON) stated the social history/trauma and cultural assessment was the facility's trauma screening. It was done within 7 days of a Resident's admission to the facility by Case Manager #1, who worked in the behavioral health clinic.
When asked about Resident #3's identified trauma history, the DON stated that Resident #3's trauma should have been included in his/her care plan but was unsure if it would continue to be on his/her care plan at this time.
Review of Resident #3's Care Plan Report which included all active, cancelled, and resolved care plan items since admission, revealed no care plan items relating to the resident's history of trauma.
Review of Resident #3's first Care Plan Conference Summary after admission, dated [DATE] at 10:00 AM, revealed no documentation regarding the resident's history of trauma.
Review of the facility policy Assessments, Care Plans, and Care Conferences, last reviewed [DATE], revealed: .
Each resident's care is based upon a comprehensive assessment with the utmost consideration of individual needs and preferences to ensure care is culturally-competent and trauma-informed.
Review of the facility policy Trauma Informed Practice, last reviewed [DATE], revealed: .
Trauma Informed Care (TIC): ?Trauma-informed care is a strengths based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.'.
Policy: CCMC [Cordova Community Medical Center] will create and maintain a safe, calm, and secure environment with supportive care, a system-wide understanding of trauma prevalence and impact, recovery and trauma specific services, and recovery-focused, client-driven services.
Early Screening and Comprehensive Assessment of Trauma.
The initial (first encounter with the agency) intake, assessment, and documentation process includes questions designed to sensitively and respectfully explore prior (including early childhood) and current trauma-related experiences.
The screening and assessment process is sufficiently thorough and focused on trauma-related issues to allow for the determination of a diagnosis associated with trauma, such as PTSD [post-traumatic stress disorder].
The ongoing process allows for the gathering of new trauma related information leading to potential changes in diagnosis as well as appropriate treatment objectives, goals, and services.
Sound Alternatives [The community behavioral health clinic] provides trauma-related information that will assist other service providers to develop a service plan that will promote effective care and reduce the likelihood of retraumatization.
025028 03/16/2026
Cordova Community Med Ltc 602 Chase Ave Cordova, AK 99574
Review of Resident #3's SOCIAL HISTORY/ Trauma and Cultural Assessment, dated [DATE],
trauma needs.) Trauma- son died at age of 21 in a motorcycle wreck.
Resident had difficulty coping with loss.
Resident states 1st husband was untruthful.
Family describes a lot of arguing among her and spouse.
Significant Life Experiences.
Marital years. 1st marriage described as volatile.
Review of Resident #3's Care Plan Report which included all active, cancelled, and resolved care plan items since admission, revealed no care plan items relating to the resident's history of trauma.
Review of the facility policy Trauma Informed Practice, last reviewed [DATE], revealed: .
Trauma Informed Care (TIC): ?Trauma-informed care is a strengths based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.'.
Policy: CCMC [Cordova Community Medical Center] will create and maintain a safe, calm, and secure environment with supportive care, a system-wide understanding of trauma prevalence and impact, recovery and trauma specific services, and recovery-focused, client-driven services.
Early Screening and Comprehensive Assessment of Trauma.
The initial (first encounter with the agency) intake, assessment, and documentation process includes questions designed to sensitively and respectfully explore prior (including early childhood) and current trauma-related experiences.
The screening and assessment process is sufficiently thorough and focused on trauma-related issues to allow for the determination of a diagnosis associated with trauma, such as PTSD [post-traumatic stress disorder].
The ongoing process allows for the gathering of new trauma related information leading to potential changes in diagnosis as well as appropriate treatment objectives, goals, and services.
Sound Alternatives [The community behavioral health clinic] provides trauma-related information that will assist other service providers to develop a service plan that will promote effective care and reduce the likelihood of retraumatization.
025028 03/16/2026
Cordova Community Med Ltc 602 Chase Ave Cordova, AK 99574
During an interview on 3/9/26 at 3:42 PM, [NAME] #3 stated Use By dates on food items would be treated as an expiration date. [NAME] #3 further stated the two pantry items identified were expired and the freezer foods past their use by date should have been discarded. [NAME] #3 acknowledged the bulk bin finding upon discovery.
Review of the facility policy Meal Times/Nourishments, last reviewed 1/24/25, revealed: .
Nourishments prepared by the FNS Department will be covered, and labeled with a Use By Date. and will be monitored by FNS for outdates.
Bulk nourishments are provided and stored in dining room.
All individual and bulk nourishments are for the use of residents and patients only.
025028 03/16/2026
Cordova Community Med Ltc 602 Chase Ave Cordova, AK 99574
During an interview on 3/12/26 at 3:50 PM, the Director of Nursing (DON) stated that they do not have TIC training.
During an interview on 3/12/26 at 9:15 AM, the DON stated TIC training was not listed in the facility assessment and should have been part of the assessment