Wildflower Court
WILDFLOWER COURT in JUNEAU, AK — inspection on June 12, 2026.
Found 6 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
During an interview on 6/9/26 at 1:02 PM, Resident #39 stated that he/she had a history of trauma and PTSD and that knocking on his/her door was a known trigger.
When the resident desired privacy, he/she shut the door and preferred that staff comply with a posted sign that requested staff use the mounted doorbell instead of knocking. An observation on 6/9/26 at 1:15 PM, revealed Certified Nursing Assistant (CNA) #2 approached Resident #39's room while surveyors conducted an interview with the resident. CNA #2 knocked on the resident's door and rang the mounted doorbell. CNA #2 then opened the door. Resident #39 stated, Not now, I'm busy, and CNA #2 closed the door.
Further observation revealed a paper sign posted on the outside of Resident #39's door that read, Pls. [please] Ring the Bell, Don't Knock! STOP A doorbell was mounted next to the sign.
During an interview on 6/11/26 at 9:50 AM, the Assistant Director of Nursing (ADON) stated all staff members received training on traumaˆinformed care and PTSD during new hire orientation.
She stated that staff were aware of Resident #39's preference to use the doorbell, and her expectation was that staff honor the resident's wishes.
During an interview on 6/11/26 at 11:00 AM, CNA #9 stated all staff received traumaˆinformed care training during orientation and annually. He/she further stated staff are informed about residents with PTSD and their triggers, which included the reason behind each trigger.
Knocking was a known trigger for Resident #39 which would make him/her very upset, and that staff were to comply with the posted sign and use the doorbell.
Review of Resident #39's care plan, initiated 4/3/26, revealed: .
Problem: Resident has a potential for OR actual psychosocial well being issue d/t [due to]: hx [history] of past trauma.
Approach: Encourage resident to voice concerns/feelings; provide reassurance as needed.
Approach: Determine resident's expectations and discuss in realistic terms.
Review of the facility policy Trauma- Informed and Culturally Competent Care, undated, revealed: .
Purpose. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization.
Trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening.
All staff are provided in-service training about trauma and trauma-informed care in the context of the healthcare setting.For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. e.
Empowerment, voice and choice: (1) Ensure that the resident's choices and preferences are honored and that residents are empowered to be active participants in their care.(4) Avoid one-size-fits-all approaches, which can make individuals feel discounted.
025027 06/12/2026
Wildflower Court 2000 Salmon Creek Lane Juneau, AK 99801
[DATE] at 11:53 AM, the Administrator acknowledged the facility used a generic Form CMS-10123
025027 06/12/2026
Wildflower Court 2000 Salmon Creek Lane Juneau, AK 99801
Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility
has multiple regulatory requirements.
Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status;. (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.
Further review of the RAI User's Manual, Chapter 2, stated that an Item Set refers to the MDS items that are active on a particular assessment type or tracking form and that the Comprehensive (NC) [annual] Item Set and Quarterly (NQ) Item Set consists of the items active on an annual and quarterly assessment.
Review of the CMS MDS 3.0 Item Matrix v1.20.1v4, dated 10/2025, revealed Section D (Mood) and Section E (Behavior) items are active on the NC-Comprehensive and NQ Quarterly Assessment item set
025027 06/12/2026
Wildflower Court 2000 Salmon Creek Lane Juneau, AK 99801
Review of Davis's Drug Guide for Nurses, copyright 2026 revealed potential side effects for oxycodone included: orthostatic hypotension (a drop in blood pressure upon standing that can lead to dizziness or fainting), blurred vision, confusion, sedation, dizziness, floating feeling, and hallucinations.
Further review revealed the black box warning: . use with benzodiazepines or other CNS depressants, including other opioids, nonbenzodiazepine sedative/hypnotic, anxiolytics, general anesthetics, muscle relaxants antipsychotics may cause profound sedation, respiratory depression, coma and death.
Review of Resident #39's care plan revealed no interventions addressing medication related fall risk, despite documentation that Resident #39 experienced three falls within approximately one month and received multiple high-risk medications associated with dizziness, sedation, impaired coordination, and orthostatic hypotension.
Review of the facility policy Managing Falls and Fall Risk - Resident-Centered Approaches to Managing Falls and Fall Risk, undated, revealed: .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) for falls for each resident at risk for or with a history of falls. If underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment of the nature or category of falling until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable .
Review of the facility policy Falls-Clinical Protocol, undated, revealed: .The physician will help identify individuals with a history of falls and risk factors for falling.
The staff and practitioner will review each resident's risk factors for falling and document in the medical record.
Examples for risk factors include light headedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension and medical conditions affecting the central nervous system.
Treatment/Management. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessments of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation .
Review of the facility policy Care Plan Goals and Objectives, undated, revealed: .When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goal and objectives have been established.
Care plans will be modified accordingly .
Review of Resident #17's care plan dated 5/11/26,
resident's room. On both attempts, the monitor located at the nurses' station failed to illuminate or
then changed the batteries, but did not test it to see if it would work.
During the same interview, both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall receiving training regarding operation or testing of the monitoring devices.
Both CNAs stated they rounded on everyone regularly.
During the interview, Resident #17's bed monitor activated and emitted a faint chime. CNA #1 stated he/she could not hear the soft chime down the hallway or in another resident's room.
The CNA further added that if they were turned up, they would be able to hear them.
During an interview on 6/11/26 at 3:54 PM, the Facility Director (FD) stated the facility did not perform preventive maintenance on the Smart Caregiver monitoring devices and relied on staff to ensure the devices functioned properly.
The FD was unable to provide the manufacturer's operating instructions for the remote monitors.
Review of the Smart Caregiver Cordless Caregiver Alert Monitor Installation and Use Instructions, undated, accessed at: https://smartcaregiver.com/pages/instructionitem/chair-and-bed-alarm-with-wireless-monitor, revealed: .Test the System.
Test all components before use.
Smart CordLess utilize wireless technology which is subject to physical and environmental considerations.
These products do not have an out of range function and as such should be tested periodically in the setting in which they are to be used to understand their area of effective operation . We recommend that all personnel receive periodic training in the operation of these systems and that the systems are tested before each use .
The Smart Caregiver Corporation wireless device is designed to be installed by the end user. As such, it is the entire responsibility of the buyer to verify that Smart CordLess products are properly installed and tested successfully, before each use, in the setting in which they are to be used .
The system is not designed to replace good caregiving practices including, but not limited to: A.) Direct patient supervision, B.) Adequate training for staff personnel in fall management and elopement, C.) Testing of the system before each use.
Review of the facility-provided policy, Managing Falls and Fall Risk, undated, revealed: .The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.
025027 06/12/2026
Wildflower Court 2000 Salmon Creek Lane Juneau, AK 99801
Review of the CDC Food Service Guidelines for Federal Facilities, dated 2017, revealed: .
Food Safety Standards.
The United States government works to protect the American public from foodborne illnesses through the collaborative efforts of HHS's [U.S.
Department of Health and Human Services] Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), and USDA's [U.S.
Department of Agriculture] Food Safety and Inspection Service. FDA publishes the Food Code, which provides guidance for a uniform system of addressing food safety issues in all retail food and food service establishments, such as restaurants, cafes, and cafeterias.
While not a regulation itself, the Food Code has served as the primary model for retail food regulations and ordinances at state, local, and tribal levels since the publication of the first edition in 1993. It has also served as the basis for food safety policy and recommendations of numerous federal agencies that have responsibility for the oversight of food service and retail facilities on federal property.
The primary Food Safety standard in the Food Service Guidelines for Federal Facilities states that contractors operating in federal facilities are expected to adhere to the most recently published Food Code.
Food Preparation Contamination An observation on 6/10/26 at 10:40 AM, in the main kitchen, revealed [NAME] #7 preparing raw chicken thighs on a stainless steel table and sheet pan using kitchen shears while wearing gloves.
During the observation, [NAME] #7 stopped food preparation, walked to a speaker that was playing music, touched the speaker to turn it off while wearing the same gloves used during raw chicken preparation, then returned to the food preparation area and resumed handling raw chicken without removing the contaminated gloves or performing hand hygiene.
During an interview on 6/12/26 at 10:27 AM, the DCNS stated [NAME] #7 should not have touched the speaker with contaminated gloves.
The DCNS stated the expectation was for the cook to remove gloves before touching the speaker, wash hands, and put on clean gloves before returning to food preparation.
During an interview on 6/11/26 at 10:10 AM, the Infection Preventionist (IP) stated the facility's infection prevention program included all departments and that new employees received infection prevention education during orientation, including hand hygiene, standard precautions, and cleaning and disinfection.
The IP further stated staff were educated to use soap and water when hands were visibly soiled.
Review of the facility policy Food Storage, Handling and Preparation, undated, revealed: . R.9.
Wash hands:. R.9.2.
Immediately before preparing food or handling equipment. R.9.3. As often as necessary during food preparation when contamination occurs.
R.9.4. when you return to your work station. R.9.5.
When switching between working with raw foods and working with ready-to-eat or cooked foods. R.9.8.
After touching door knobs or handles. R.9.11.
Any other time an unsanitary task has been performed.
025027 06/12/2026
Wildflower Court 2000 Salmon Creek Lane Juneau, AK 99801
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.