Maple Springs Of Palmer
Inspection history, citations, penalties and survey trends for this long-term care facility in Palmer, Alaska.
- Location
- 12130 East Maple Springs Way, Palmer, Alaska 99645
- CMS Provider Number
- 025039
- Inspections on file
- 24
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Maple Springs Of Palmer during CMS and state inspections, most recent first.
A resident with multiple neurological and mental health diagnoses reported concerns about staff using profanities and inappropriate names. The allegation was disclosed during an IDT meeting attended by the Administrator, DON, and Resident Advocate, but no formal investigation was conducted and the incident was not reported to the State Survey Agency within the required timeframe, contrary to facility policy.
A resident with multiple neurological and mental health diagnoses reported being verbally abused by a nurse, including the use of profanities and derogatory language. The facility did not conduct a formal investigation, failed to report the incident to the State Survey Agency, and allowed the alleged staff member to continue working in the resident's unit, contrary to facility policy.
The facility did not perform required monthly inspections or maintain documentation for seven facility-owned Hoyer lifts and personal mechanical lifts used by two residents. One resident experienced a lift tipping incident during a transfer, and neither resident had physician orders or care plan documentation for the use of personal lifts. The Maintenance Director and Administrator confirmed that inspections and maintenance logs were not completed as required.
The facility did not report injuries of unknown origin and allegations of abuse or neglect to the Resident Advocate and State Survey Agency within the required timeframes for three residents. In each case, there were significant delays in reporting incidents involving forceful handling, unexplained bruising, and neglect related to incontinence care, despite facility policy requiring immediate notification.
Two residents with severe cognitive impairment were involved in separate incidents where allegations of abuse and injuries of unknown origin were not thoroughly investigated. In both cases, the facility did not assess non-interviewable residents for signs of abuse, nor did it interview all staff who had provided care to the affected residents, resulting in incomplete investigations as required by facility policy.
A resident with dementia, fractures, incontinence, and impaired mobility did not receive weekly skin assessments as required by facility policy. Despite being care planned for impaired skin integrity, there was no documentation of skin assessments for nearly two weeks, during which time multiple bruises and discolorations developed and were only identified later by nursing staff. Staff interviews confirmed that weekly assessments and immediate reporting of changes were expected, but these actions were not carried out.
A resident who required mechanical lift transfers was moved by a single CNA, despite facility policy requiring two staff for such transfers. During the transfer, the lift tipped over and the resident fell to the ground, resulting in tenderness to the head and back. The CNA reported that the resident often requested single-person transfers and that this was a common practice, even though all staff had been trained on the two-person policy. Staffing records indicated that additional help was available at the time of the incident.
The facility did not implement or enforce safety measures for residents who smoked or vaped, including failing to provide or require adaptive devices, not completing required safety assessments, and allowing unsecured lighters and cigarettes in resident rooms. Residents were observed smoking near entrances, discarding cigarette butts unsafely, and sustaining burn injuries, while the facility lacked fireproof receptacles and did not monitor smoking materials, placing all residents at immediate risk.
A nurse administered pantoprazole to a resident by taking it from another resident's blister pack when the medication was unavailable, without a formal tracking process and in violation of facility policy. Staff interviews confirmed this practice was not appropriate, and the incident involved a resident with complex medical needs, including quadriplegia and GERD.
The facility did not ensure that kitchen surface sanitizing solutions and fruit and vegetable cleaning solutions were maintained at proper concentrations, as required by manufacturer guidelines. Multiple observations and staff interviews revealed that solutions were below target levels, not regularly tested, and not documented, affecting all residents who received food from the kitchen.
The facility did not ensure the produce wash solution dispenser was functioning properly, resulting in repeated failures to achieve the recommended antimicrobial concentration for cleaning fresh produce. Despite available test strips and posted instructions, there was no formal process or documentation for regular monitoring, and the dispenser was found to be empty and later malfunctioning, affecting food safety for residents.
A resident with multiple medical conditions was left exposed by a CNA during toileting assistance, as the CNA walked away to empty a urinal without covering the resident's buttocks and genitals. The resident expressed discomfort with the situation, and the DON acknowledged that leaving a resident exposed was not ideal. Facility policies require staff to maintain resident dignity and respect during care.
A resident with paralysis and total dependence on staff for bed mobility was repeatedly found with the call light out of reach, despite care plan instructions and staff awareness of the need for accessibility. The resident, unable to use one side of the body, resorted to whistling or yelling for help. Facility policies lacked specific procedures to ensure call lights were always within reach.
A resident with hemiplegia and hemiparesis, who was nonverbal and fully dependent on staff, did not have an individualized care plan addressing communication needs. The care plan inappropriately included interventions such as use of a call light, which the resident could not operate, and lacked guidance for staff on how to communicate or assess the resident's well-being. Staff and the POA expressed concerns about misinterpretation of the resident's cues and the use of pain medication without first trying non-pharmacological interventions.
The facility did not update care plans for two residents after significant changes in their medical care, including discontinuation of contact precautions and antibiotics for one resident with a stage 4 pressure ulcer, and failure to add anticonvulsant use and remove enteral feeding interventions for another resident with anoxic brain damage and seizures. Nursing staff and the DON confirmed that care plans were not revised to reflect these changes, despite facility policy requiring timely updates.
Surveyors identified infection control deficiencies involving two residents: one had soiled suction tubing and an uncovered yankauer tip in contact with the wall, while another had a urinary catheter drainage bag resting on the floor. Staff interviews and policy reviews confirmed these practices did not meet facility standards for aseptic technique and sanitary equipment handling.
The facility did not display variance decisions in a location readily accessible to residents and the public, as required by state law. The posting was initially placed in a restricted area near office supply shelves by Administration offices, which was not accessible to the public, and only later moved to a more visible area. This failure denied all residents and their representatives access to information about the criminal history of facility employees.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to immediately report an allegation of verbal abuse to the State Survey Agency as required by federal regulations. During an IDT care conference, a resident with diagnoses including Parkinson's disease, anxiety disorder, PTSD, and depression expressed concerns about the use of profanities and inappropriate names by a staff member. When questioned further, the resident identified the staff member involved. Despite this disclosure, no formal investigation was conducted, and the incident was not reported to the State Survey Agency within the required two-hour timeframe. Interviews confirmed that the Administrator, DON, and Resident Advocate were present during the meeting when the allegation was made and were aware of the resident's concerns. The facility's own abuse policy mandates immediate reporting of all abuse allegations, but this protocol was not followed. The failure to report the alleged verbal abuse promptly had the potential to place vulnerable residents at risk.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to respond appropriately to an allegation of verbal abuse involving one resident with a history of Parkinson's disease, anxiety disorder, PTSD, and depression. The resident and their representative reported that a licensed nurse used profanities and derogatory language towards the resident on multiple occasions. The resident expressed unhappiness and fear of retaliation, and the concern was also documented during an IDT care conference. Despite these allegations, the facility did not conduct a thorough or formal investigation, nor did they document any inquiry into the matter. The incident was not reported to the State Survey Agency as required, and there was no evidence that the facility followed its own abuse policy regarding investigation and reporting. Additionally, the alleged staff member continued to work scheduled shifts, including in the unit where the resident resided, while the allegations were unresolved. The facility's abuse policy mandates immediate reporting, investigation, and removal of the alleged perpetrator from resident contact until the investigation is complete. However, these steps were not taken, and there was no documentation of witness interviews or notification to the resident's family or legal representative. The lack of action left the resident at risk of continued abuse and contributed to their distress.
Failure to Conduct Required Monthly Inspections of Mechanical Lifts
Penalty
Summary
The facility failed to conduct required monthly inspections of all seven facility-owned Hoyer (mechanical) lifts, as well as personal mechanical lifts owned by two residents. According to the facility's policy and the manufacturer's manual, monthly inspections and maintenance logs are required to ensure the safety and functionality of these lifts. The Maintenance Director admitted that inspections were not performed as frequently as required and that no maintenance logs were kept. The Administrator confirmed that there was no documentation of maintenance or inspection for any of the lifts. One resident, who was cognitively intact and dependent on staff for transfers, experienced an incident where her personal mechanical lift tipped over during a transfer, though she was not injured. There was no documentation in her care plan or physician orders regarding the use of her personal lift, nor any record of monthly inspections. The resident stated that the facility did not inspect her lift, and the Maintenance Director confirmed no inspections were performed on it. A second resident, who was severely cognitively impaired and also dependent on staff for transfers, had a personal mechanical lift in his room. There was no physician order or care plan documentation for the use of this lift, and no evidence of monthly inspections. The Maintenance Director confirmed that he had not inspected this lift either. The Administrator acknowledged that neither resident's personal lift had been assessed for safety and that the facility lacked documentation of required inspections.
Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin and allegations of abuse and neglect immediately to the Resident Advocate (RA) and within two hours to the State Survey Agency (SSA) for three residents reviewed for abuse and neglect. According to the facility's policy, all such incidents should be reported immediately, but not later than two hours if serious bodily injury is involved, or within 24 hours if not. However, in each of the three cases, there were significant delays in reporting. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, an incident occurred where a CNA allegedly forcefully handled the resident during care, causing the resident to cry out in pain. The CNA who witnessed the event did not report it to the nurse until nearly seven hours later, and the incident was not reported to the RA or SSA until many hours after that. The initial report submitted to the SSA was blank and did not contain any information regarding the allegation. Another resident with severe cognitive impairment and a history of fractures was found with multiple bruises of unknown origin. The bruising was identified by staff, but the initial report to the SSA was not submitted until approximately five hours after discovery. In a third case, a resident with hemiplegia and vascular dementia was found in a saturated brief and bedding, leading to an allegation of neglect. The incident was reported to the administrator and RA with significant delays, and the SSA was not notified until 18.5 hours after the initial allegation. In all cases, staff and administration interviews confirmed that reporting did not occur within the required timeframes.
Failure to Thoroughly Investigate Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin for two residents with severe cognitive impairment. In the first case, a resident with dementia and a history of behavioral issues was allegedly subjected to rough handling by a CNA during incontinence care, as reported by another CNA. The investigation did not include a physical assessment of the resident for signs of abuse, nor were other non-interviewable residents under the care of the accused CNA assessed. Only four residents were interviewed, and not all relevant staff were interviewed or provided written statements. The CNA accused of abuse was suspended but returned to work and completed required abuse training only after working several shifts without having done so. In the second case, another resident with dementia and multiple fractures was found with multiple bruises of unknown origin. The investigation included interviews with the nurse and CNAs present at the time the bruising was discovered, as well as three alert residents on the same floor. However, there was no documentation that staff who had cared for the resident in the days prior were interviewed to determine the cause of the bruising or why it had not been reported earlier. Additionally, other non-interviewable residents on the same floor were not assessed for signs of abuse or neglect. Facility policy required that all allegations of abuse or neglect, including injuries of unknown origin, be thoroughly investigated, with all pertinent information reviewed, witnesses identified, and interviews conducted with all relevant parties. The failure to assess non-interviewable residents for signs of abuse and to interview all staff involved in the care of the affected residents resulted in incomplete investigations, as confirmed by facility leadership during interviews.
Failure to Complete Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to complete routine weekly skin assessments for one resident, as required by its own policy. The resident, who had diagnoses including dementia, fractures, incontinence, and impaired mobility, was care planned for impaired skin integrity and at risk for pressure ulcer development. Despite these risks and the care plan interventions specifying adherence to facility protocols for skin breakdown prevention, there was no documented evidence of skin assessments from 04/02/25 through 04/13/25. The last documented skin assessment was on 04/01/25, and the next was not until 04/13/25, when multiple bruises and areas of discoloration were observed and documented by nursing staff. Interviews with staff confirmed that weekly skin assessments were expected and that any changes in skin integrity should be reported immediately. However, the absence of documentation and delayed identification of bruising indicated that these assessments were not performed as required. The Corporate Quality Nurse confirmed the lack of documented assessments during the specified period and acknowledged that the bruising might have been identified sooner if the assessments had been completed as per policy.
Failure to Follow Two-Person Mechanical Lift Policy Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident who required mechanical lift transfers was moved by a single certified nurse aide (CNA), contrary to the facility's policy mandating two staff members for such transfers. The resident, who was cognitively intact and dependent on staff for transfers due to diagnoses including hypertensive heart and chronic kidney disease with heart failure, was being transferred from bed to wheelchair using a Hoyer lift. During the transfer, the lift tipped over, causing the resident to fall to the ground while still in the lift. The CNA involved reported that the resident typically requested only one CNA for transfers and that this practice was common among staff, despite the policy requiring two staff members. The incident was documented in the resident's progress notes, which described the fall and subsequent assessment revealing tenderness to the head and back. The CNA's statement confirmed that she was the only aide assigned to the resident's hall at the time and that she attempted the transfer alone, as was reportedly the resident's preference. Other staff members interviewed confirmed their understanding of the two-person policy for mechanical lifts and stated that they would call for assistance when needed. The resident also confirmed that she had previously requested single-person transfers but acknowledged the incident and stated that staff now use two people for her transfers. Review of facility records showed that the CNA involved had received training and signed an agreement to follow the lift safety policy, which explicitly required two staff for mechanical lift transfers. Staff competency records indicated that all nursing staff had been assessed as competent in using mechanical lifts. Staffing records for the day of the incident showed that there were multiple aides and nurses on duty, suggesting that additional help was available. The deficiency was identified through observation, interviews, and record review, which established that the facility failed to ensure adherence to its own policy, resulting in an unsafe transfer and a fall.
Failure to Ensure Safe Smoking and Vaping Practices Creates Immediate Jeopardy
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards, specifically related to smoking and vaping practices among residents. Multiple residents who smoked or vaped were not provided with appropriate safety measures, such as the use of required adaptive devices like smoking aprons, despite assessments indicating their necessity. Observations revealed that residents smoked near facility entrances and discarded cigarette butts on the ground or in non-fireproof trash cans containing ignitable materials, with no fireproof receptacles available. Additionally, residents were observed smoking without the required adaptive equipment, and some had visible burn injuries and burn holes in their clothing as a result of unsafe smoking practices. Annual smoking safety screening assessments were not completed for several residents who smoked, and no safety assessments were performed for residents who used electronic cigarettes (vapes). The facility's policy stated it was a smoke-free and vape-free campus, requiring residents and staff to smoke or vape off property, but in practice, residents continued to smoke on or near the property without supervision or designated safe areas. Interviews with residents and staff confirmed that residents kept their own cigarettes and lighters in their rooms or on their person, and the facility did not maintain accountability for these items. Resident rooms were unsecured and often left open, increasing the risk of access to lighters and smoking materials by other residents, including those with cognitive impairments. The lack of secure storage for lighters, absence of fireproof receptacles, failure to enforce the use of adaptive safety devices, and incomplete or missing safety assessments for both smokers and vapers created an environment with immediate risk of injury or death. These deficiencies were observed through direct observation, interviews, and record reviews, and affected multiple residents with significant medical histories, including those with paralysis, cognitive impairment, and other serious health conditions. The situation resulted in an immediate jeopardy finding under CFR 483.25(d) Accidents.
Improper Medication Administration from Another Resident's Supply
Penalty
Summary
A Licensed Nurse (LN) administered a dose of pantoprazole to a resident by removing the medication from a blister pack labeled for a different resident. The LN stated that when a resident's medication was unavailable, they would borrow the same medication from another resident's supply if both were prescribed the same drug. The LN did not have a formal process for tracking borrowed medications, instead relying on verbal communication with the oncoming nurse or returning the medication if working the next day. This practice was observed during a medication pass and confirmed through interviews with the LN and other staff. Record reviews showed that both residents had physician orders for pantoprazole, but the facility's policy explicitly prohibited administering medications ordered for one resident to another. Interviews with another LN and the Director of Nursing confirmed that this practice was not appropriate and was against facility policy. The incident involved a resident with significant medical needs, including quadriplegia and GERD, and demonstrated a failure to ensure that nursing staff had the appropriate competencies to administer medications accurately.
Failure to Maintain Proper Sanitizer and Produce Wash Concentrations
Penalty
Summary
The facility failed to maintain proper concentrations of kitchen sanitizing solutions and fruit and vegetable cleaning solutions, as required by professional standards and manufacturer guidelines. Observations revealed that multiple red buckets labeled for Ecolab sanitizing solution were used throughout the kitchen, including at the food preparation line, dishwashing station, and food preparation sinks. When tested with manufacturer-provided test strips, the sanitizer solutions in these buckets consistently showed concentrations below the required target levels. Staff interviews confirmed that while the solutions were supposed to be changed every one to two hours and tested for concentration, there was no documentation or log of when tests were performed or their results. Additionally, the facility's own policy required regular testing and documentation, which was not followed. Further observations showed that the Ecolab Antimicrobial Fruit & Vegetable Treatment dispenser, used to wash produce before serving, was not dispensing solution at the recommended concentration. Test strips indicated a dilution ratio of zero, and the solution container was found to be empty. Even after replacing the container, the dispenser continued to fail to deliver the correct concentration due to a suspected air blockage and a malfunctioning motor, as later confirmed by a technician. There were no logs maintained to document the testing of the produce wash solution, and staff relied on periodic, undocumented checks. These deficiencies affected all 57 residents who received food from the kitchen, as the improper concentrations of sanitizing and cleaning solutions created a potential for foodborne illness and cross-contamination. The lack of proper monitoring, documentation, and maintenance of both the surface sanitizer and produce wash solutions directly led to the facility's failure to meet required food safety standards.
Failure to Maintain Functional Produce Wash Dispenser in Kitchen
Penalty
Summary
The facility failed to ensure that the produce wash solution dispenser used in the kitchen was operating correctly, which affected the cleaning of fresh produce served to 57 residents. Observations revealed that the dispenser for Ecolab Antimicrobial Fruit & Vegetable Treatment was present and test strips were available, but when the solution was tested directly from the dispenser, the test strips consistently indicated a dilution ratio of 0, showing that the solution was not at the manufacturer's recommended concentration. It was discovered that the solution container was empty, and after replacement, the dispenser still failed to deliver the correct concentration. Further inspection by the kitchen manager suggested that air in the line was preventing proper dispensing, and later, a technician identified a malfunctioning motor as the cause. Interviews revealed that there were no logs maintained to document regular testing of the solution's concentration, and the kitchen manager relied on periodic checks during dining services. The facility's only guidance for monitoring the solution was a manufacturer’s poster instructing staff to periodically check the wash solution using test strips. There was no formal policy or process in place to ensure consistent monitoring or documentation of the solution’s concentration.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to maintain a resident's dignity during personal care. The resident, who had a history of Parkinson's disease, left femur fracture, osteoporosis, strokes, and heart failure, required extensive assistance for toileting. During an observed episode, the CNA pulled down the resident's shorts and brief, exposed the resident's buttocks and genitals, and then walked away to empty a urinal, leaving the resident exposed until the CNA returned to complete care. The resident later reported feeling uncomfortable with being left exposed, and the Director of Nursing acknowledged that such exposure during care was not ideal. Facility policies reviewed emphasized the importance of resident dignity and respect during care, including during lifting and movement. The incident demonstrated a failure to provide care in a manner that promoted dignity and respect for the resident.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was consistently within reach, as required to reasonably accommodate the resident's needs and preferences. The resident, who had a history of dysphagia following a nontraumatic intracerebral hemorrhage, unspecified dementia with behavioral disturbances, seizures, and anemia, was observed multiple times lying in bed with the call light out of reach, specifically between the headboard and mattress. The resident was totally dependent on staff for repositioning and turning in bed and was unable to use the left side of the body due to a stroke. The care plan specified that the call light should be within reach and that safety checks should occur every hour. Interviews with the resident, the resident's representative, and staff confirmed that the call light was often not accessible, leading the resident to whistle or yell for help instead. The facility's policies on routine resident checks and call light use did not include procedures to ensure the call light was always within reach. Documentation and staff interviews further indicated that the resident required assistance with bed mobility and that the lack of access to the call light was a recurring issue.
Failure to Individualize Care Plan for Nonverbal Resident with Communication Needs
Penalty
Summary
The facility failed to develop and implement an individualized care plan that addressed the specific communication needs of a nonverbal resident with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage. The resident was entirely dependent on staff for all care and interactions, unable to move any part of their body, and could not use a call light. Despite this, the care plan included interventions such as ensuring the call light was within reach and encouraging its use, which were not appropriate for the resident's condition. There was no documentation or guidance for staff on how to communicate with the resident or how to assess the resident's well-being, particularly in relation to pain management. Interviews with staff and the resident's POA revealed concerns that staff may have been misinterpreting the resident's nonverbal cues, leading to the administration of non-scheduled pain medication without first attempting non-pharmacological interventions, as preferred by the POA. The CNA interviewed confirmed the absence of written guidance on communication strategies for the resident, and the DON acknowledged that the care plan should have been individualized to include communication needs and that the call light intervention was not suitable for this resident.
Failure to Update Care Plans After Changes in Resident Status and Treatment
Penalty
Summary
The facility failed to update and revise care plans for two residents following significant changes in their medical status and treatment. For one resident with quadriplegia, orthopedic aftercare, and a stage 4 pressure ulcer, the care plan continued to reflect the use of contact barrier precautions and antibiotic therapy for MRSA, despite both interventions having been discontinued. Observations showed signage for enhanced barrier precautions at the resident's doorway, but interviews with nursing staff confirmed that neither contact precautions nor doxycycline therapy were still in place. The care plan, last revised prior to these changes, was not updated to reflect the discontinuation of these interventions. For another resident with anoxic brain damage and unspecified convulsions, the care plan did not include the initiation of anticonvulsant medications, despite provider orders and medication administration records confirming ongoing use of Keppra and clobazam. Additionally, the care plan continued to reference enteral feedings via PEG tube, even though the PEG tube had been removed, enteral feedings discontinued, and the resident was transitioned to an oral diet. Documentation in provider orders, nursing notes, and surgical consults confirmed the removal of the PEG tube and the resident's ability to eat by mouth, but the care plan was not revised to reflect these changes. Interviews with the Director of Nursing confirmed that the care plans for both residents were not updated as required following changes in their conditions and treatments. Facility policy requires ongoing assessment and timely revision of care plans to reflect current standards of practice and resident needs, but this was not followed in these cases.
Infection Control Deficiencies in Suction Equipment and Catheter Bag Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper handling and maintenance of medical equipment for two residents. For one resident with central pontine myelinolysis, contractures, and muscle spasms, observations revealed that the suction canister tubing was stained brown and the yankauer suction tip was uncovered and touching the wall. The tubing and tip remained in this unsanitary condition for several days, despite facility policy requiring replacement every 7 days or when visibly soiled. The Infection Preventionist confirmed that the tubing should have been changed when soiled and that the yankauer should not have been stored in contact with the wall. Another resident with quadriplegia, cerebral palsy, and neuromuscular bladder dysfunction was observed with a urinary catheter drainage bag resting on the floor. Staff interviews confirmed that drainage bags should not be placed on the floor and that facility policy requires catheter tubing and drainage bags to be kept off the floor to maintain aseptic technique. The improper positioning of the drainage bag was acknowledged as an infection control concern by both nursing and infection prevention staff.
Failure to Post Variance Decisions in a Conspicuous Location
Penalty
Summary
The facility failed to comply with state law requiring the posting of variance decisions in a conspicuous location accessible to residents and the public. Observations on 3/23/25 revealed that there were no visible postings of variance decisions in areas readily accessible to residents or the public throughout the facility. When questioned, the HR Director indicated that the posting was located beside office supply shelves at the end of a back hallway near the Administration offices, an area only accessible by walking behind the receptionist's desk or through a conference room. The Director of Nursing confirmed that this location was not accessible to the public. The deficiency was further substantiated when the HR Director later stated that the variance decision posting was relocated to a wall in the main plaza area by the dining room entrance. The lack of proper posting denied all residents and their representatives, based on a census of 60, the right to knowledge regarding the criminal history of facility employees, as required by 7 AAC 10.940. The report does not mention any specific residents or their medical conditions in relation to this deficiency.
Latest citations in Alaska
A resident with ESRD and dependence on hemodialysis did not receive post-dialysis care according to physician orders, the care plan, and facility policy. The post-dialysis pressure dressing on the AV fistula was not documented as removed within the ordered timeframe, despite dialysis center instructions specifying timely removal. Although an LN later reported that the access site was bleeding and a dressing change was performed, the TAR documented the site as clear and nursing notes did not reflect any dressing change. Required shift assessments of the fistula site for bleeding, redness, and tenderness were not accurately documented, and there was no evidence that the physician was notified of the bleeding access site, contrary to facility policy and referenced CDC dialysis safety standards.
The facility failed to obtain and document informed consent for psychotropic medications before administration for multiple residents with dementia, Parkinson’s disease, and related behavioral and psychotic disturbances. In several cases, residents had OPA guardians or other representatives as medical decision-makers, yet there was no evidence that risks, benefits, alternatives, or treatment options for medications such as divalproex, valproic acid, olanzapine, quetiapine, pimavanserin, and antidepressants were discussed or that representatives were given an opportunity to choose among options. For one resident, consent for quetiapine was signed after the first dose had already been given. Staff interviews showed confusion about who was responsible for obtaining informed consent, when it should occur, and which medications required it, and leadership acknowledged that consents obtained via email were not consistently placed in the medical record and that consent audits were irregular, despite facility policies and resident rights documents requiring that residents or representatives be advised of psychotropic risks and benefits and that this be documented.
The facility failed to maintain sufficient RN, LPN, and CNA staffing levels as defined in its own facility assessment, particularly on weekends, and frequently relied on float staff to cover cottages without regularly assigned nurses. Staff and a resident reported that only one nurse and one CNA sometimes covered an entire cottage, that CNAs from other cottages had to pick up assignments when someone called in, and that staff shortages caused rushing and concerns about care. One resident with quadriplegia, fully dependent for bathing and preferring showers, missed multiple scheduled showers over several weeks and instead received bed baths or no documented hygiene care, and reported long call-light response times and staff declining small assistance due to being too busy. Another resident with multiple sclerosis and functional quadriplegia, dependent on staff and an overhead lift for transfers, was not consistently gotten out of bed on the days specified in their care plan and grievance resolution, and reported that requests to get up were often denied or deferred because staff said they were shorthanded.
A resident with multiple medical and psychiatric diagnoses, under a full court-appointed guardianship granting the guardian authority over medical and mental health treatment, was sent to a behavioral health consultation without documented notification to the guardian. The consultation report noted the resident was unescorted, that there was documentation of a guardian/POA, and that the resident could not state why they were there, with a recommendation to obtain guardian contact. The Administrator and DON confirmed there was no documented guardian notification, and although the AA reported that transportation was provided and that the resident’s recent BIMS showed intact cognition, there was no chart documentation that the guardian had been informed of or consented to the mental health appointment.
Two residents did not receive ADL services as assessed and care planned. A resident with quadriplegia, fully dependent on staff and preferring showers, was care planned for twice-weekly showers using a Carendo chair, but logs and interview showed prolonged gaps without showers and missed scheduled shower days, with staff citing CNA shortages and long call-light response times. Another resident with multiple sclerosis and functional quadriplegia, dependent on staff for bed-to-chair transfers, had a care plan and CNA tasks specifying transfers to a chair multiple times per week, and had previously expressed concerns and filed a grievance about limited opportunities to get out of bed; however, task logs showed the resident was either not gotten up or only once per week over several weeks, and the resident reported staff often declined requests to get up due to staffing and workload.
Two residents were discharged without adequate planning, resulting in unsafe and inappropriate transitions. One was sent home to an inaccessible and unsafe environment without necessary support or services, leading to distress, a fall, and reliance on unplanned third-party assistance. Another was discharged despite unresolved behavioral and cognitive issues, without required mental health referrals or involvement of their representative, causing distress and confusion. The facility lacked documented discharge planning standards and failed to coordinate essential post-discharge care.
A resident with dementia, depression, anxiety, and other complex conditions was admitted without the PASRR Level II report being available or reviewed. The facility did not initiate specialized mental health services as required, delayed updating the care plan, and discharged the resident without addressing PASRR-identified needs or following recommended discharge options. This resulted in untreated behavioral symptoms and increased psychotropic medication use.
A resident with complex medical needs developed multiple pressure ulcers and infections due to the facility's failure to provide timely and consistent wound care interventions, delayed care planning, poor documentation of noncompliance, and lack of coordination for higher-level wound care referrals. Discrepancies between wound care provider recommendations and actual treatment orders, as well as improper antibiotic administration in relation to dialysis, contributed to persistent wound infection and ultimately led to hospitalization with sepsis and death.
Systemic failures in the QAPI program led to ongoing deficiencies in staffing, grievance procedures, activities, medication management, and therapy services. Residents experienced long wait times for assistance, were not properly informed about grievance processes, and were not consistently offered activities as documented in their care plans. Incomplete narcotic count documentation and lapses in therapy services further contributed to suboptimal care.
Two residents did not receive care according to physician orders and care plans. One resident with hypertension and heart failure had daily vital signs ordered but only had them documented twice over several months. Another resident with skin breakdown risk had orders for offloading boots and wound care that were not implemented, as observed during the survey. Facility policies required adherence to these orders and care plans.
Failure to Follow Post-Dialysis Orders and Document AV Fistula Complications
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related treatment and care in accordance with physician orders, the resident’s care plan, and facility policy for one resident dependent on hemodialysis with ESRD and PVD. Physician orders and the MAR directed that the post-dialysis pressure dressing on the resident’s AV fistula be removed after a specified number of hours, and dialysis communication from the dialysis center reiterated that the fistula dressing must be removed within a defined timeframe to prevent clotting or narrowing of the AV graft. Record review showed no documentation that the post-dialysis dressing was removed within the ordered timeframe, and there was no indication on the MAR or in nursing progress notes that a dressing change was performed during the relevant dates. The facility also failed to assess, document, and communicate the condition of the dialysis access site as ordered and per policy. The care plan required daily checks and dressing changes at the access site with documentation and monitoring for signs and symptoms of complications, and the TAR included an order to assess the fistula site every shift for clarity, tenderness, redness, and bleeding. A nurse reported that upon the resident’s return from dialysis, the access site was bleeding and a dressing change was performed, but the TAR documentation for that shift indicated the site was “clear,” and nursing progress notes contained no record of a dressing change. Additionally, despite facility policy requiring monitoring for complications and immediate physician notification for bleeding, the medical record contained no evidence that the physician was notified about the post-dialysis bleeding AV fistula. CDC dialysis safety guidelines cited in the report state that standards of care require reassessment of the access site after dressing removal for bleeding, redness, or swelling, with accurate documentation and timely communication of findings, which was not demonstrated in this case.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to administration, thereby failing to ensure residents or their representatives were informed in advance of the risks, benefits, alternatives, and options for treatment. For Resident #1, who had severe dementia with psychotic disturbance, anxiety disorder, and depressive disorder, the record showed extensive use of multiple psychotropic medications, including divalproex, lorazepam, olanzapine, quetiapine, sertraline, and trazodone over a defined period. The resident had an Office of Public Advocacy (OPA) guardian as medical decision-maker, yet there was no documented informed consent for any of these medications. Emails to the guardian referenced that Depakote and other psychotropics had been ordered or adjusted, but did not include information on risks, benefits, alternatives, or options, nor did they document that the guardian was given an opportunity to choose a preferred option. The guardian later stated the facility had never reviewed risks, benefits, alternatives, or options for any medications and that such information would have guided decision-making. For Resident #3, who had vascular dementia and cerebrovascular disease and also had an OPA guardian, the medical record showed long-term administration of valproic acid and a period of mirtazapine use, totaling hundreds of psychotropic medication administrations. The record contained no documented informed consent for these medications. A progress note indicated that a licensed nurse was unable to reach the resident’s representative and mailed a copy of notes, including the addition of mirtazapine, but there was no further documentation of efforts to contact the representative to discuss medications or obtain informed consent. The facility was unable to provide any proof of informed consent for Resident #3’s psychotropic medications, and the guardian similarly stated that information on risks and benefits would have guided decision-making. For Resident #4, who had Parkinson’s disease with dyskinesia, dementia due to Parkinson’s disease with behavioral disturbance, hallucinations, and Lewy body dementia with psychotic disturbance, the record showed an order and ongoing administration of pimavanserin, an antipsychotic, over approximately 90 days. The resident had a representative who made medical decisions, but there was no documented informed consent for this psychotropic medication, and the facility could not provide any proof when requested. For Resident #5, diagnosed with dementia with behavioral disturbance and Parkinson’s disease, quetiapine was ordered and first administered before the facility obtained a signed Psychotropic Risk/Benefits Verification of Informed Consent form; the consent was dated one day after the first dose was given. This demonstrated that consent was not obtained prior to initial administration. Interviews with nursing staff and leadership revealed confusion and inconsistency regarding responsibility for obtaining informed consent, when it should be obtained, and where it was documented. One licensed nurse believed physicians were ultimately responsible for obtaining consent and was unsure where signed consents were stored. Another nurse did not know who was responsible, when to obtain consent, or how to verify its presence before administering a new medication, and believed only antipsychotics required consent. A third nurse assumed that if a physician wrote an order, informed consent had already been obtained, and identified psychotropics and antipsychotics as requiring consent that included discussion of risks and benefits. The DON and LTC nurse manager stated that bedside nurses were trained to obtain informed consent before the first dose of medications needing consent and that the facility did not obtain new informed consent for psychotropics if a resident was already taking the same medication on admission, assuming the resident already knew the risks and benefits. The LTC nurse manager also stated that consents were sometimes obtained via email to representatives or guardians, but copies of those emails were not placed in the medical record, and audits of consents had not been done regularly. These practices conflicted with the facility’s resident rights document and its psychopharmacological drug use policy, both of which required that residents or their representatives be advised of potential risks and benefits of psychotropic medications and that this be documented.
Insufficient Nursing Staff Leading to Missed ADLs and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff, including CNAs and licensed nurses, to meet residents’ needs as established in its own facility assessment. The assessment specified minimum staffing levels of 6–8 licensed nurses on day shift, 5–7 licensed nurses on night shift, 8–10 CNAs on day shift, and 7–8 CNAs on night shift. Review of staffing schedules for December 2025 and January 2026 showed that on multiple weekend days, the number of licensed nurses and CNAs scheduled fell below these minimums. On specific dates, day and night shifts were staffed with fewer licensed nurses than required, and several day and night shifts were staffed with fewer CNAs than the assessment’s minimums. Payroll Based Journal data further showed the facility triggered for low weekend staffing for all four quarters of federal fiscal year 2025, establishing a history of low weekend staffing. In addition to low numbers, staffing patterns showed that licensed nurses and CNAs frequently picked up resident assignments in cottages that did not have regularly assigned staff. Staff interviews confirmed that some cottages, such as Aniak, did not have a regular nurse assigned and instead relied on float nurses from other cottages. A CNA reported feeling unable to provide good quality care because of rushing and expressed concern about resident falls due to having only one nurse and one CNA in the cottage. Another nurse stated there was only one CNA caring for residents and that if that CNA called in sick, CNAs from other cottages would pick up assignments. An anonymous resident reported that staff shortages were a big problem, with shared nurses and CNAs, and described long waits and receiving bed baths instead of showers when CNAs did not have time. The insufficient staffing directly affected the provision of ADLs for specific residents. One resident with quadriplegia, dependent on staff for showers and whose care plan required showers every Sunday and Thursday night using a Carendo chair, did not receive showers as scheduled. Shower logs showed a 14-day gap between showers in December 2025, with bed baths documented instead on some scheduled shower days and no documentation of shower or bed bath on another scheduled day in January 2026. This resident stated they had not been showered for three weeks in December and again on a recent scheduled day because staff told them there were not enough CNAs, and also reported long waits for call light responses and staff declining to assist with small tasks due to being too busy. Another resident with multiple sclerosis, muscle weakness, and functional quadriplegia, who was dependent on staff for transfers and required one-person assistance with an overhead lift, experienced reduced opportunities to get out of bed. Social service documentation noted the resident’s interest in being transferred to a chair more than once a week and identified staffing concerns as a primary factor because the transfer was a two-person assist, leading to decreased participation in usual activities when left in bed. The resident later filed a grievance stating they were concerned about only being able to get out of bed once per week and had been told this limitation was due to staffing, requesting to get up three times per week. CNA task logs showed that over several weeks in December 2025 and early January 2026, the resident was not consistently gotten up on the scheduled days, including an entire week with no documented transfers out of bed. The resident reported that when they asked to get up, staff often responded that they would see, which usually meant no, citing being shorthanded or too many people getting up at once.
Failure to Notify Guardian of Behavioral Health Consultation
Penalty
Summary
The facility failed to ensure a court-appointed guardian was informed of and able to participate in care decisions for a resident with multiple complex medical and mental health diagnoses, including multiple sclerosis, renal tubule-interstitial disease, bipolar disorder, delusional disorder, and anxiety disorder. The resident had a LETTER OF GUARDIANSHIP dated 4/17/14 that appointed the Office of Public Advocacy as full guardian, with explicit authority over medical care, mental health treatment, physical and mental examinations, and approval of all medications, medical procedures, and psychotropic medications. Despite this, the resident was sent to a behavioral health consultation on 10/22/25, during which the consultation report documented that the patient was unescorted, that documentation at the time of the visit indicated a guardian/POA, and that the patient was unable to explain the reason for the visit. The consultant recommended obtaining more information about the reason for the visit and guardian contact. Interviews and document reviews showed there was no documented guardian notification regarding the scheduled psychiatric consultation. The Administrator and DON confirmed there was no documented guardian notification. The staffing schedule for the date of the appointment noted the resident needed an escort, but the DON could not verify who the escort was. An email from the Assistant Administrator stated that the facility’s driver provided transportation and ensured check-in, and referenced a recent BIMS indicating intact cognition, which the facility typically used to determine that an escort was not required. The same email and a follow-up email acknowledged that it was standard practice to notify residents and representatives of appointments, but there was no documentation in the chart confirming guardian notification for this mental health appointment. The guardian later stated it was possible they had been made aware but could not recall due to a large caseload, and there was no facility documentation verifying that notification or consent had occurred.
Failure to Provide ADL Care per Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) services in accordance with assessed needs, care plans, and resident preferences for two residents. One resident with quadriplegia was care planned to receive showers every Sunday and Thursday night using a Carendo chair and was documented on the MDS as being fully dependent on staff for bathing. The resident’s MDS also reflected a preference for showers. Progress notes reiterated the order for showers every Sunday and Thursday night with licensed nurse skin evaluations. Despite this, the December shower log showed the resident did not receive a shower between 12/18 and 12/28 and instead received bed baths on two of those days, and the January log showed missed scheduled showers on 1/1 and 1/5, with only a bed bath documented on 1/1 and no shower or bed bath documented on 1/5. During interview, this resident stated they were dependent on staff for ADLs such as showering and reported not receiving a shower for three weeks in December and again on the prior day because staff told them there were not enough CNAs available. The resident also reported long waits for call light responses, sometimes 30–40 minutes, and stated that staff told them they were too busy when the resident requested assistance with smaller tasks such as getting water or adjusting the TV volume, even when staff were already in the room. The Director of Nursing reported that showers were audited twice a week and discussed during rounds and that CNAs were supposed to notify a nurse or supervisor if a resident did not receive a shower. The second resident had multiple sclerosis, muscle weakness, and functional quadriplegia and was documented on the MDS as having upper and lower limb impairments and being dependent on staff for bed-to-chair transfers. The care plan required supervision and physical assistance with transfers using a one-person overhead lift. A social service note documented that the resident wanted to be transferred to a chair more than once a week, identified staffing as a barrier due to being a two-person transfer, and reported decreased participation in usual activities when left in bed. A grievance later documented the resident’s concern about only being able to get out of bed once per week and their request to get up on Monday, Wednesday, and Friday. CNA task documentation directed staff to ensure the resident was up every Monday, Wednesday, and Friday, but the task log showed that over several weeks in December and early January the resident was either not gotten up at all or only once per week on specified dates. In interview, the resident stated they did not get out of bed twice during December and that when they asked to get up, staff often responded that they would see, which usually meant no due to being short-handed or too many people getting up at once, despite the plan of care specifying three times per week.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure that residents were discharged in a manner that protected their health, safety, and psychosocial well-being. Specifically, the facility did not develop or implement an effective discharge planning process for two residents, resulting in unsafe and inappropriate discharges. The facility lacked documented standards for discharge planning, relying instead on verbal expectations within the social services department. Discharge planning was limited to care conferences at admission and two weeks prior to discharge, with no ongoing reassessment or structured involvement of resident representatives. The facility also did not conduct home visits prior to discharge, and referrals for post-discharge services and equipment were inconsistently arranged or delayed. One resident was discharged to a home environment that was known to be unsafe and inaccessible, without adequate caregiver support or required services in place. The resident, who had a history of joint replacement surgery, infection, and a recent femur fracture, required wound care, mobility assistance, and ongoing medical follow-up. Despite the resident's home being multi-level, in disrepair, and infested with rodents, the facility proceeded with discharge planning that did not ensure safe access or adequate support. The resident was left reliant on unplanned third parties, such as the fire department and community members, for essential care and experienced distress, emotional harm, and physical compromise, including a fall after discharge. Another resident with cognitive impairment, acute behavioral changes, and a documented need for nursing facility level care and specialized mental health services was discharged without required referrals or representative involvement. The facility did not review or incorporate the resident's PASRR Level II findings into the discharge plan, nor did it address a documented change in condition on the day of discharge. As a result, the resident experienced distress, confusion, and loss of security, with the POA having to assume unplanned caregiving responsibilities to prevent harm. The failures in discharge planning led to actual physical and psychosocial harm for both residents.
Failure to Incorporate PASRR Level II Findings into Care and Discharge Planning
Penalty
Summary
The facility failed to comply with PASRR (Pre-admission Screening and Resident Review) requirements by not incorporating the PASRR Level II determination into the assessment, care planning, and discharge planning for a resident with multiple mental health diagnoses. The PASRR Level II evaluation, which identified the need for continued nursing facility services and specialized mental health services, was not available at the time of admission and was not reviewed during the resident's stay or at discharge. The Level II report was only retrieved after the resident had already been discharged, and its recommendations were not integrated into the resident's care plan or discharge process. The resident in question had a complex medical history, including dementia, depression, anxiety, delirium, encephalopathy, and a recent femur fracture with surgical site infection. The PASRR Level II assessment specifically noted the need for specialized services to address mental health needs and provided recommendations for care and discharge options. Despite these findings, the facility did not order or initiate any specialized mental health services during the resident's stay. The care plan was delayed and, when eventually updated, did not include the specialized services recommended by the PASRR Level II evaluation. Throughout the resident's admission, there were documented episodes of aggression, combativeness, and non-compliance, which led to the initiation and escalation of psychotropic medications. The discharge summary and post-care instructions did not address the need for specialized mental health services or follow the recommended discharge options outlined in the PASRR Level II report. Facility staff acknowledged that the lack of access to and review of the PASRR Level II report negatively impacted the adequacy of care planning and discharge for the resident.
Failure to Provide Appropriate Pressure Ulcer Care and Timely Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a facility-acquired pressure ulcer. The resident, who had significant comorbidities including end-stage renal disease and diabetes, developed multiple wounds during their stay, including a left iliac crest pressure injury and sacral wounds. There were significant delays and inconsistencies in wound assessment and treatment orders, with documented discrepancies between wound care provider recommendations and the actual orders transcribed and implemented by nursing staff. For example, wound care interventions recommended by the wound care team were not consistently reflected in the Treatment Administration Record (TAR), and antibiotics were not always administered as prescribed, particularly in relation to the resident's dialysis schedule, resulting in subtherapeutic dosing. Documentation revealed that wound care interventions were not promptly added to the resident's care plan, with a delay of 21 days after wounds were first identified. There was also a lack of documentation regarding the resident's reported noncompliance with repositioning and wound care, as noted by the wound care provider, with no corresponding nursing or CNA notes, risk/benefit documentation, or care plan updates to address these issues. Additionally, there was a failure to initiate and document referrals for higher-level wound care as recommended by external providers, and the facility did not coordinate or document efforts to ensure the resident attended outpatient wound care or follow-up appointments, despite family requests and external provider recommendations. Throughout the resident's stay, wound healing was minimal, and infections persisted despite multiple rounds of antibiotics, which were at times administered incorrectly or not as ordered. The lack of timely and appropriate wound care interventions, poor communication and documentation among staff, and failure to coordinate necessary higher-level care contributed to the resident's hospitalization with sepsis and subsequent death. The facility's actions and inactions directly resulted in a deficiency related to the provision of pressure ulcer care and prevention of new ulcers.
Systemic QAPI Failures Result in Multiple Deficiencies Across Facility Operations
Penalty
Summary
The facility failed to develop, implement, and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, analyzed, and corrected systemic quality deficiencies. Despite collecting data from various sources such as electronic health records, staffing reports, maintenance logs, and resident council feedback, the QAPI committee did not effectively use this information to identify trends, prioritize high-risk issues, or implement and sustain corrective actions. This resulted in ongoing patterns of deficient practice in areas including staffing, grievance process, clinical care, activities, medication management, therapy services, discharge planning, environmental conditions, and care planning. Internal reports, resident council concerns, medical record documentation, staffing data, and direct observation all indicated these issues, but they were not recognized or acted upon through the QAPI process. Staffing deficiencies were evident, particularly on weekends, where staffing levels consistently fell below the facility's own assessment standards. Payroll Based Journal (PBJ) data and review of staffing schedules showed that the number of nurses, CNAs, and restorative aides scheduled was frequently less than the minimum required. Residents reported long wait times for assistance, with one resident waiting over two hours to be helped out of bed, and another experiencing delays in having a urinal emptied. Resident council meeting minutes repeatedly documented concerns about inadequate staffing and slow response times, with little evidence of effective facility response or improvement. The administrator and QAPI committee were not aware of the low weekend staffing, relying instead on reports that did not reflect actual staffing shortages. Additional deficiencies included failures in the grievance process, where residents were not properly informed of the current grievance officer, and posted information was outdated. Residents and council members were unaware of the new grievance officer, and there was no documentation of her introduction or updated contact information. The activities program was also deficient, with multiple residents reporting that they were not offered or able to participate in activities as documented in their care plans and assessments. Activity flowsheets showed minimal or no activity participation or offers for extended periods. Medication management was compromised by incomplete narcotic count documentation, with missing required signatures in narcotic logbooks across multiple units and months. Physical therapy services were not provided as ordered for a resident due to staff absence, with no evidence of alternative arrangements or continuity of care.
Failure to Follow Physician Orders and Care Plans for Vital Signs and Pressure Reduction
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and person-centered care plans for two residents. For one resident with a history of hypertension, heart failure, and transient ischemic attack, there was a physician's order for daily vital signs and an order for antihypertensive medication. However, record review showed that vital signs were only documented twice over a period of 177 days, despite the daily order. The acting DON confirmed that daily monitoring should have occurred, and facility policy required vital signs to be monitored as ordered for residents on antihypertensive medications. For another resident with diagnoses including weakness, mild cognitive impairment, and osteoarthritis, there were orders for wound care to leave the left heel open to air and to use offloading boots for the left lower extremity. Observation revealed the resident was lying in bed with both heels on the mattress and covered by non-skid socks, with no offloading boots in place. The care plan did not include interventions for keeping the left heel open to air or for the use of offloading boots, and a licensed nurse confirmed the order for heel boots. Facility policy required care plans to reflect services necessary to maintain the resident's highest practicable well-being and to follow recognized standards of practice.
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