Maple Springs Of Wasilla
Inspection history, citations, penalties and survey trends for this long-term care facility in Wasilla, Alaska.
- Location
- 3265 E Meridian Loop, Wasilla, Alaska 99654
- CMS Provider Number
- 025038
- Inspections on file
- 18
- Latest survey
- July 3, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Maple Springs Of Wasilla during CMS and state inspections, most recent first.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A nurse administered an anti-seizure medication orally to a resident with a PEG tube, despite the physician's order specifying administration via the tube. The resident had transitioned to oral intake after a swallow study, but the medication order was not updated to reflect this change, resulting in a medication error.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility failed to ensure residents were informed and consented to psychotropic medications, using forms with photocopied signatures and lacking proper documentation. Multiple residents had consent forms that were incomplete, missing, or signed after medication administration, placing them at risk for unnecessary medication and adverse reactions.
The facility failed to ensure that POLST forms were completed and signed by physicians, affecting both sampled and unsampled residents. Nurses completed these forms upon admission, using photocopied signatures of the Medical Director and another physician, rather than obtaining original signatures. This practice did not comply with the requirement for health care providers to review and sign the forms, potentially denying residents the opportunity to discuss life-sustaining options with an authorized provider.
The facility failed to ensure accurate completion of Psychotropic Medication Informed Consent forms, with issues such as photocopied signatures, missing consents, and incorrect documentation. These deficiencies affected multiple residents, leading to incomplete and inaccurate medical records, risking inconsistencies in care.
The facility failed to notify the Alaska LTCO of facility-initiated transfers for two residents, one with sepsis and quadriplegia and another with cardiac arrest and hypertensive heart disease. The responsible staff had resigned, and notifications for May 2024 were not sent, contrary to the facility's policy.
The facility failed to develop comprehensive care plans for two residents who smoke, potentially placing them at risk. One resident with multiple health issues was observed smoking without a smoking assessment or care plan. Another resident with nicotine dependence was found smoking without protective measures, and their care plan lacked smoking-related information. The DON confirmed the absence of smoking assessments and care plans.
The facility failed to update care plans for two residents, one requiring support during appointments due to a locked-in state, and another with dementia experiencing frequent falls and behavioral issues. The care plans lacked necessary interventions, such as accompaniment during appointments, fall prevention measures, and strategies for managing aggression, leading to deficiencies in care.
The facility failed to ensure that a CNA and an LN had valid CPR certificates, with the CNA working 17 days and the LN 7 days without valid certification. The HRD was unaware of the expiration, and the facility lacked a formal CPR policy, risking timely emergency care for residents.
A facility failed to adhere to a care plan requiring two staff for a resident's bed mobility, leading to improper repositioning by a single CNA. Additionally, neurological assessments for a resident with multiple falls were incomplete, often skipped when the resident was asleep. Furthermore, three residents were not assessed for safe smoking practices, despite keeping smoking materials in their rooms, contrary to the facility's smoke-free policy.
A facility failed to complete a comprehensive admission assessment for a resident with Parkinson's disease and neurocognitive disorder using the MDS within the required 14-day period. Key sections of the MDS were still 'In Progress' beyond the deadline, potentially leading to inaccurate health assessments and inconsistent care. The MDS Nurse acknowledged the oversight, which involved critical areas such as cognitive patterns and mood.
A resident diagnosed with severe vascular dementia with psychotic disturbance was not reassessed within 14 days as required. Despite significant changes in behavior and mood, including hallucinations and suicidal thoughts, a Significant Change in Status Assessment was not completed. The facility's MDS Nurse and DON acknowledged the oversight, which contributed to the deficiency.
A facility failed to provide documented ROM exercises to a resident with quadriplegia, as required to maintain mobility. The resident reported not receiving therapy, and although the RNA claimed to provide exercises, there was no documentation due to issues with the electronic health record system. The DON was unaware of the documentation failure until the surveyor's inquiry.
A facility failed to review a hospice resident's drug regimen, leading to potential unnecessary medication administration. The resident, with dementia and a history of stroke, was prescribed Morphine Sulfate with a dosage range order lacking specific parameters. This resulted in frequent administration of the maximum dose. Interviews revealed a lack of oversight and coordination in medication management, with no specific policy for hospice care.
The facility failed to maintain the walk-in freezer door's gasket, leading to a persistent puddle of water in front of the freezer door inside the walk-in refrigerator. Observations over several days showed the gasket was compromised, with rubber-like material hanging from the door. Dietary staff were unaware of the issue until it was pointed out, and a maintenance request was submitted but not resolved during the survey. The facility also lacked the freezer's user guide or manual.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Medication Administered by Incorrect Route
Penalty
Summary
A deficiency occurred when a licensed nurse administered an anti-seizure medication, levetiracetam oral solution, by mouth to a resident who had a physician's order specifying administration via PEG tube. The resident, who had a history of intracranial injury, gastrostomy, and post-traumatic seizures, was observed taking the medication orally despite the order indicating the PEG tube route. The nurse explained that the resident had transitioned to oral intake following a swallow study, but the PEG tube remained in place pending reassessment for removal. However, the medication order had not been updated to reflect this change in administration route. Interviews with nursing staff and the Director of Nursing confirmed that any changes to medication administration routes should be documented in the electronic health record and communicated to the nursing staff. The facility's policy and standard nursing procedures require medications to be administered as prescribed, including the correct route. The failure to update the physician's order and administer the medication as ordered resulted in a medication error for the resident.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Obtain Proper Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the use of psychotropic medications. The facility used a Psychotropic Medication Informed Consent and Risk/Benefit Statement form to educate and obtain consent from residents or their representatives. However, the forms were not completed accurately or timely, and often contained photocopied signatures of the Medical Director instead of original signatures from healthcare providers. This practice was confirmed by the Medical Director, who stated that she approved the use of her photocopied signature on blank consent forms for repeated use. The review of records revealed multiple instances where consent forms for psychotropic medications were either missing, not obtained prior to medication administration, or not accurately completed. For example, some forms had photocopied signatures, lacked staff signatures to indicate who provided education or obtained consent, or were signed after the medication had already been administered. In some cases, consent forms were not updated to reflect changes in medication dosage, and there were instances where consent was documented as obtained via telephone, but there was no follow-up documentation to confirm this. The deficiency involved numerous residents who were on psychotropic medications, including antidepressants, anxiolytics, and antipsychotics. The failure to properly inform residents and obtain valid consent placed them at risk for unnecessary medication and adverse reactions. The facility's policy on psychotropic medication use, dated December 2023, was not adhered to, as evidenced by the incomplete and improperly signed consent forms found in the residents' medical records.
Deficiency in POLST Form Completion and Signature Verification
Penalty
Summary
The facility failed to ensure that physicians completed the Physician Orders for Life-Sustaining Treatment (POLST) forms with residents, and that these forms were signed and dated with an original signature. This deficiency was identified for 9 sampled residents and 35 unsampled residents. The POLST forms, which are crucial for clarifying life-sustaining measures such as CPR and medically assisted nutrition, were completed by nurses upon admission rather than by physicians. The forms contained photocopied signatures of the Medical Director and another physician, rather than original signatures, indicating that the forms were not properly reviewed or signed by the authorized health care providers. Interviews with licensed nurses and the Medical Director revealed that the practice involved using photocopied signatures on blank POLST forms, which were then filled out during the admission process. The Medical Director admitted to approving the use of her photocopied signature and confirmed that there was no documentation in the resident charts to indicate that health care providers had reviewed the admission paperwork, including the POLST forms. This practice potentially denied residents the opportunity to be offered life-sustaining options by an authorized health care provider, as required by the facility's procedures.
Deficiencies in Psychotropic Medication Consent Documentation
Penalty
Summary
The facility failed to ensure that medical records were accurately completed in accordance with accepted professional standards of practice. Specifically, the facility did not properly complete the Psychotropic Medication Informed Consent and Risk/Benefit Statement forms for residents on psychotropic medications. These forms were not completed accurately, timely, or by authorized healthcare providers with an original signature. The report highlights that the Medical Director's signature was photocopied on blank consent forms, which were then used during resident admissions without proper review or authorization. The report details numerous instances where consent forms for psychotropic medications were either missing, not obtained prior to medication administration, or inaccurately completed. For example, several residents had consent forms with photocopied signatures of the Medical Director, and in some cases, the forms lacked signatures from staff who provided education or obtained consent. Additionally, some consent forms were completed after the medication had already been administered, and in other cases, the forms did not specify the correct dosage or medication class. These deficiencies in documentation and consent processes created incomplete and inaccurate medical records, placing residents at risk for inconsistencies in care and treatment. The report provides specific examples of residents who were affected by these practices, including instances where consent was not obtained for medication dosage changes or where consent forms were not properly filled out or signed by the appropriate parties.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that transfer notices for three residents were sent to the Alaska Office of the State Long Term Care Ombudsman (LTCO). This deficiency was identified during a record review and interviews, revealing that the facility did not notify the LTCO of facility-initiated transfers for two residents. One resident was admitted with sepsis and quadriplegia and was transferred to the emergency department due to uncontrolled pain and a leg discrepancy. Another resident, admitted with cardiac arrest and hypertensive heart disease, was hospitalized for pulmonary edema. In both cases, there was no record of LTCO notification. Interviews with the Director of Nursing and the Administrator revealed that the staff responsible for sending these notifications had resigned, and the facility had not sent the required notifications for May 2024. The Administrator confirmed that the Ombudsman's office had only received notifications for January, March, and April 2024. The facility's policy requires that a copy of the transfer or discharge notice be sent to the LTCO at the same time it is provided to the resident and their representative, which was not adhered to in these instances.
Failure to Address Smoking Needs in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the smoking needs of two residents, which could potentially place them at risk for harm. Resident #11, who was admitted with multiple diagnoses including a right ankle fracture, diabetes, high blood pressure, and acute respiratory failure, was observed smoking outside without a smoking assessment or focused care plan addressing this behavior. The facility's records did not include a smoking assessment for Resident #11, and the Director of Nursing (DON) confirmed the absence of such an assessment. Similarly, Resident #33, who had a left below-the-knee amputation, peripheral vascular disease, and nicotine dependence, was found to be rolling and smoking cigarettes without wearing a protective apron. Despite being identified as a smoker in the MDS assessment, there was no care plan addressing smoking for Resident #33. The DON acknowledged the lack of smoking assessments and care plans for both residents, indicating that smoking-related information was not being transferred from the admission assessments to the care plans.
Failure to Revise Care Plans for Resident Needs
Penalty
Summary
The facility failed to revise comprehensive care plans to meet the changing needs of two residents, leading to deficiencies in their care. One resident, who was in a locked-in state and unable to communicate verbally, attended a dental appointment alone without the necessary support from a guardian or staff member. This occurred because the care plan did not include an intervention to ensure accompaniment during appointments, despite it being a well-known requirement among staff. The resident's mother reported that the appointment was distressing for the resident, who experienced choking and was unable to communicate effectively. Another resident, admitted under hospice care with dementia and a history of falls, experienced 28 falls over eight months. The facility's care plan for this resident was not updated in a timely manner to include interventions such as fall mats, chair and bed alarms, and increased toileting and monitoring. Although these interventions were discussed in fall huddles and some were implemented, they were not consistently documented in the care plan, leading to a lack of coordinated care to prevent further falls. Additionally, the facility did not adequately address the behavioral and emotional needs of the second resident, who had a history of aggressive behavior due to dementia. Although staff were trained on specific techniques to minimize agitation and aggression, these strategies were not incorporated into the resident's care plan. This omission meant that not all staff were aware of the best practices for interacting with the resident, potentially exacerbating the resident's behavioral issues.
Failure to Maintain Valid CPR Certification for Staff
Penalty
Summary
The facility failed to ensure that two nursing staff members, a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN), had valid Cardiopulmonary Resuscitation (CPR) certificates. CNA #3 was hired with an expired CPR certificate and worked for 17 days without a valid certificate. The Human Resources Director (HRD) was unaware of the expiration until the CNA provided a valid CPR card on a later date. Similarly, LN #7 worked for 7 days with an expired CPR certificate, mistakenly believing it was valid for the entire month. The HRD confirmed that the LN worked on the floor for two weeks without a valid CPR certificate. The HRD stated that the facility conducted CPR training monthly, and CNAs without active CPR certificates were not allowed to provide CPR during emergencies. Instead, other staff with active CPR certifications would intervene. However, the facility lacked a formal CPR policy, as evidenced by the Employee Handbook, which only required employees to provide evidence of passing a First Aid/CPR class within the first 30 days of hire. This oversight placed all residents at risk of not receiving timely CPR or emergency care when needed.
Deficiencies in Care Plan Adherence, Neurological Assessments, and Smoking Safety
Penalty
Summary
The facility failed to ensure that the care plan for a resident with multiple complex medical conditions, including quadriplegia and a stage 4 pressure ulcer, was followed regarding the number of staff required for safe bed mobility. Observations revealed that a CNA repositioned the resident in bed with a one-person assist, contrary to the care plan that required two staff members. This discrepancy was confirmed by interviews with staff, who indicated that the CNAs did not have direct access to the care plan and relied on report sheets and other sources that did not specify the required number of staff for bed mobility. The facility also failed to conduct accurate neurological assessments for a resident with a history of multiple unwitnessed falls. The review of neurological assessment flow sheets showed numerous instances where assessments were incomplete or not conducted at all, often documented as the resident being asleep. The Director of Nursing acknowledged the expectation for complete and accurate assessments and noted previous staff education on the importance of conducting these assessments, even if the resident was sleeping. Additionally, the facility did not assess three residents for the safe storage of smoking paraphernalia, despite their known smoking habits. Observations and interviews revealed that these residents kept cigarettes and lighters in their rooms without documented assessments or care plans addressing smoking safety. The Director of Nursing confirmed the lack of smoking assessments and acknowledged the facility's policy as a smoke-free campus, which was not effectively enforced or monitored, leading to potential safety hazards.
Failure to Complete Timely Admission Assessment
Penalty
Summary
The facility failed to complete a comprehensive admission assessment for a resident using the Resident Assessment Instrument 3.0 Minimum Data Set (MDS), which is a federally required nursing assessment for long-term care residents. This deficiency was identified for one resident out of 14 sampled. The resident in question was admitted with diagnoses including Parkinson's disease and neurocognitive disorder with Lewy bodies, both of which require careful monitoring and assessment to ensure appropriate care. However, upon review, it was found that key sections of the MDS, such as Identification, Hearing, Speech, and Vision, Cognitive Patterns, Mood, and Care Areas Assessment Summary, were still marked as 'In Progress' beyond the required completion timeframe. The MDS Nurse confirmed during an interview that the comprehensive admission assessment should have been completed within 14 days of the resident's admission, which was not adhered to in this case. The resident's care plan, dated prior to the required completion date, highlighted several focus areas, including hearing impairment, use of anti-anxiety and anti-depressant medications, and impaired cognitive function related to dementia. The failure to complete the assessment in a timely manner had the potential to result in inaccurate health and functional status assessments, placing the resident at risk for inconsistent care.
Failure to Reassess Resident After Dementia Diagnosis
Penalty
Summary
The facility failed to complete a comprehensive reassessment within 14 days after a resident was diagnosed with severe vascular dementia with psychotic disturbance. The resident was admitted with diagnoses including cardiac arrest and hypertensive heart disease with heart failure. On a later date, the resident was diagnosed with severe vascular dementia, which was characterized by intense agitation, anxiety, and hallucinations. Despite these significant changes in the resident's condition, a Significant Change in Status Assessment (SCSA) was not completed, and the last Interdisciplinary Team (IDT) meeting occurred before the dementia diagnosis. The Minimum Data Set (MDS) OBRA Admission assessment initially indicated no behavioral symptoms or mood issues, but subsequent records showed the resident experiencing hallucinations and expressing suicidal thoughts. The facility's MDS Nurse acknowledged that the dementia diagnosis might qualify as a significant change if it affected the resident's functional status, and the Director of Nursing confirmed that a SCSA should have been conducted. The failure to reassess the resident's condition and update the care plan as required by the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual contributed to the deficiency.
Failure to Provide Documented ROM Exercises for Resident with Quadriplegia
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises to a resident with quadriplegia, which was necessary to maintain their level of mobility. The resident, who was admitted with diagnoses including sepsis and quadriplegia, reported difficulty moving their arms and stated they had not received therapy. The Minimum Data Set (MDS) Admission Assessment indicated impairments in both upper and lower extremities, and the resident's care plan included a focus on maintaining mobility and preventing complications related to immobility. Despite the care plan's interventions, the Restorative Nurse Aide (RNA) claimed to provide ROM exercises three times a week, coordinated with a physical therapist. However, there was a lack of documentation to support this claim. The Director of Nursing (DON) acknowledged that the facility's electronic health record system, Point Click Care (PCC), was not saving RNA notes since the initiation of the RNA program, and the issue was only addressed after the surveyor's inquiry. This lack of documentation and oversight contributed to the deficiency in providing necessary care to the resident.
Failure to Review Drug Regimen for Hospice Resident
Penalty
Summary
The facility failed to review the drug regimen for a resident under hospice care, leading to the potential administration of unnecessary medications. The resident, who had dementia with agitation and a history of stroke, was prescribed Morphine Sulfate with a dosage range order that lacked specific parameters to guide administration. The medication order allowed for a range of 0.25mL to 1.0mL, but did not specify conditions under which each dose should be administered. This resulted in the resident frequently receiving the maximum dose of 1.0mL, contrary to the intended practice of starting with the lowest dose and increasing if necessary. Interviews with facility staff and hospice personnel revealed a lack of oversight and coordination in managing the resident's medication. The pharmacist acknowledged that range orders typically come from hospitals and are often discontinued for more precise orders, while the physician stated that hospice agencies had full control over the resident's care. The hospice medical director admitted that parameters were not provided with range orders, and the maximum dose was not intended to be the first option. The facility's policies on medication orders and administration did not address hospice care specifically, and the Director of Nursing confirmed the absence of a policy for hospice resident care.
Compromised Freezer Door Gasket in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen equipment in a safe operating condition, specifically the walk-in freezer door's gasket. Observations over several days revealed a persistent puddle of free-standing water in front of the walk-in freezer door, located inside the walk-in refrigerator. The gasket on the freezer door was compromised, with two dark gray strings of rubber-like material hanging from the bottom of the door. This condition was observed on multiple occasions, indicating a failure to address the issue promptly. Interviews with dietary staff revealed a lack of awareness regarding the water on the floor and the compromised gasket. Dietary staff #4 and #19 were not aware of the issue until it was pointed out during the survey. A maintenance request was eventually submitted to assess the freezer door seal, but the issue persisted throughout the survey period. Additionally, the facility was unable to provide the user guide or manual for the walk-in freezer, indicating a lack of proper documentation and maintenance oversight.
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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