ANCHORAGE, AK — Federal health inspectors found that Centennial Post Acute caused actual harm to at least one resident through failures in pressure ulcer prevention and treatment, according to findings from a complaint investigation completed on December 24, 2025. The Anchorage facility was cited for 9 total deficiencies during the inspection and, notably, has not submitted a plan of correction to address the documented problems.
The pressure ulcer citation, classified under federal regulatory tag F0686, carried a severity level of G — indicating isolated actual harm that fell short of immediate jeopardy. While the classification indicates the harm was isolated to a limited number of residents, the designation of "actual harm" means inspectors confirmed that residents experienced real, measurable negative health consequences — not merely the potential for harm.
Pressure Ulcer Care Failures Confirmed
The federal citation focused specifically on the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing. This regulatory requirement, codified under F0686, is one of the most closely monitored standards in nursing home oversight because pressure ulcers — also known as bedsores or decubitus ulcers — are widely regarded as one of the most reliable indicators of overall care quality in long-term care settings.
Pressure ulcers develop when sustained pressure on the skin reduces blood flow to the tissue, typically occurring over bony areas such as the heels, tailbone, hips, and shoulder blades. Residents who are immobile, use wheelchairs, or are confined to bed are at the highest risk. These wounds are classified on a four-stage scale, with Stage 1 involving non-blanchable redness of intact skin, and Stage 4 involving full-thickness tissue loss with exposed bone, tendon, or muscle.
The presence of a new or worsening pressure ulcer in a nursing home resident raises immediate questions about the adequacy of care being provided. Pressure ulcers are largely preventable conditions when facilities follow established clinical protocols. The development of a new pressure ulcer — or the deterioration of an existing one — typically signals breakdowns in one or more fundamental care processes.
Why Pressure Ulcer Prevention Is a Core Care Standard
Nursing facilities are required under federal regulations to ensure that residents who enter without pressure ulcers do not develop them unless clinically unavoidable, and that residents who have existing pressure ulcers receive treatment and services to promote healing and prevent infection.
Proper pressure ulcer prevention involves several interconnected care activities:
Routine skin assessments must be conducted upon admission, at regular intervals, and whenever a resident's condition changes. These assessments should document the condition of the skin over all bony prominences and identify residents who are at elevated risk.
Repositioning schedules are critical for residents with limited mobility. Clinical guidelines generally recommend repositioning immobile residents at least every two hours when in bed and every hour when seated in a wheelchair. Each repositioning should be documented, and staff should use supportive devices such as pressure-redistribution mattresses, heel elevation boots, and specialized cushions.
Nutritional support plays a significant role in both prevention and healing. Adequate protein intake, hydration, and caloric consumption are essential for maintaining skin integrity. Residents identified as being at risk for pressure ulcers should receive nutritional assessments and, when indicated, supplemental nutrition plans developed in coordination with dietary staff and physicians.
Moisture management is another critical element. Skin that is frequently exposed to moisture from incontinence, perspiration, or wound drainage breaks down more rapidly. Facilities must implement individualized continence care plans and use barrier creams and moisture-wicking products to protect vulnerable skin.
When any of these protocols fail — or when staff do not carry them out consistently — the consequences for residents can be severe and rapid.
The Medical Consequences of Inadequate Pressure Ulcer Care
Pressure ulcers carry serious medical risks that extend far beyond the wound itself. An untreated or improperly treated pressure ulcer can progress through stages quickly, sometimes advancing from intact skin to a deep, open wound in a matter of days under poor conditions.
Infection is among the most significant complications. Open pressure ulcers are vulnerable to bacterial colonization, which can lead to localized wound infections, cellulitis, or, in the most serious cases, osteomyelitis — a bone infection that can require prolonged antibiotic therapy or surgical intervention. In elderly residents with compromised immune systems, wound infections can also progress to sepsis, a life-threatening systemic infection that is one of the leading causes of death in nursing home populations.
Chronic pain is another consequence. Advanced pressure ulcers are painful, and the pain can be both constant and acute during dressing changes and repositioning. For residents who may already be dealing with multiple medical conditions, the addition of wound-related pain significantly impacts quality of life and can contribute to depression, decreased appetite, and further functional decline.
Extended healing times compound the problem. A Stage 3 or Stage 4 pressure ulcer can take months to heal even under optimal care conditions. During that time, the resident may require specialized wound care, additional medications, restricted activity, and more frequent medical monitoring — all of which represent a substantial burden on the individual and the healthcare system.
Research published in medical literature has consistently shown that the mortality rate among nursing home residents who develop pressure ulcers is significantly higher than among comparable residents without pressure ulcers. While the ulcers themselves are not always the direct cause of death, they serve as markers of overall care deficiency and are frequently associated with other unaddressed health needs.
Nine Total Deficiencies Raise Broader Concerns
The pressure ulcer citation was not an isolated finding. Inspectors documented 9 deficiencies in total during the December 2025 complaint investigation at Centennial Post Acute. While the full details of all citations were not included in the reviewed documentation, the volume of deficiencies identified during a single visit suggests systemic issues within the facility's care delivery and operational oversight.
Complaint investigations differ from standard annual surveys in an important way: they are triggered by specific allegations of harm or regulatory non-compliance, often reported by residents, family members, or facility staff. The fact that this inspection was initiated by a complaint — and resulted in nearly a dozen citations — indicates that the concerns raised by the complainant were substantiated and that additional problems were uncovered during the investigation.
The citation for pressure ulcer care fell under the broader category of Quality of Life and Care Deficiencies, which encompasses the most fundamental aspects of nursing home care. Deficiencies in this category typically reflect problems with direct resident care rather than administrative or environmental issues.
No Correction Plan Filed
Perhaps the most concerning aspect of the inspection findings is that, as of the most recent available information, Centennial Post Acute has not submitted a plan of correction to address the cited deficiencies.
Federal regulations require that when a nursing facility is cited for deficiencies, it must submit a plan of correction to the state survey agency within 10 calendar days. This plan must describe the specific actions the facility will take to correct the deficiency, how it will identify and address any residents who were affected, what systemic changes it will implement to prevent recurrence, and the date by which full compliance will be achieved.
The absence of a correction plan is significant because it means the facility has not formally committed to any specific remedial actions. Without a documented correction plan, there is no framework for follow-up inspections to verify that problems have been resolved, and there is no assurance that the conditions that led to resident harm have been addressed.
State and federal regulators have a range of enforcement tools available when facilities fail to correct cited deficiencies, including civil monetary penalties, denial of payment for new admissions, and, in the most serious cases, termination from the Medicare and Medicaid programs. The application of these enforcement actions depends on the severity and persistence of the deficiencies and the facility's compliance history.
What Families Should Know
For current and prospective residents and their families, inspection findings like those at Centennial Post Acute serve as important data points when evaluating the quality of care at a nursing facility. The Centers for Medicare & Medicaid Services (CMS) maintains a publicly accessible database at Medicare.gov's Care Compare tool where consumers can review inspection results, staffing levels, and quality measures for every Medicare- and Medicaid-certified nursing home in the country.
When reviewing a facility's record, families should pay particular attention to:
- Severity levels of citations (Level G and above indicate actual harm occurred) - Patterns of repeated citations for the same deficiency across multiple inspections - Whether correction plans were submitted and implemented in a timely manner - The scope of deficiencies — whether problems are isolated or widespread
A single citation does not necessarily define the overall quality of a facility, but the combination of actual harm, multiple deficiencies, and the absence of a correction plan warrants careful consideration and follow-up by anyone with a loved one currently receiving care at the facility.
The full inspection report for Centennial Post Acute is available through CMS and provides additional detail on all nine deficiencies cited during the December 2025 investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Centennial Post Acute from 2025-12-24 including all violations, facility responses, and corrective action plans.
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