Maple Springs of Palmer

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1) drugs and biologicals used in the facility were properly labeled; and 2) removed medications and supplies when expired in 3 medication carts, out of 5 total carts, and 1 medication room, out of 2 storage rooms inspected. Specifically, the facility failed to: 1) label opened glucometer test-strip containers used in four units (Willow, Susitna, Denali, and [NAME]); and 2) remove expired medications and supplies from three medication carts ([NAME], Denali, and Susitna) and one medication room ([NAME] Pass). These failed practices: 1) placed 13 residents (#'s 4, 7, 10, 11, 15, 18, 23, 24, 25, 31, 36, 44, and 46) at risk of inaccurate blood glucose results that could contribute to delayed or inappropriate treatment decisions; [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain complete and accurately documented medical records for 2 of 2 sampled residents (#s 32 and 40), and 2 of 2 unsampled residents (#'s 6 and 30), reviewed for Advance Directive (AD - A written instruction, such as a living will or durable power of attorney for health care, recognized under State law, that relates to the provision of health care when the individual is incapacitated) and Physician Orders for Life-Sustaining Treatment (POLST - a medical order that communicated a patient's wishes for emergency and end-of-life care) documentation. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was provided the right to be informed in advance, by the physician or other professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 resident (#7), out 13 residents reviewed for informed consent and psychotropic medication use. Specifically, the facility failed to obtain and document informed consent before Duloxetine (an antidepressant used to treat depression, anxiety, nerve pain, and certain chronic pain conditions) was initiated. This failed practice denied the resident and/or resident representative the opportunity to be informed of the medication's intended benefit, potential risks and side effects, available alternatives, and the option to accept or refuse the treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident and/or resident representative (RR) were able to exercise their right to participate in the development and revision of the person-centered plan of care for 1 resident (#40), out of 13 sampled residents. Specifically, the facility failed to provide Resident #40 and/or the resident representative the opportunity to participate in the development and revision of the person-centered care plan, including establishing expected goals, outcomes, preferences, and choices, when the facility reviewed and revised the resident's care plan between January and August 2026. This failed practice placed Resident #40 at risk of having the comprehensive care plan revised without the resident's or RR's input regarding the Resident's goals, preferences, choices, and desired outcomes of care.

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate information was provided to a receiving health care institution or provider during a transfer for 1 resident (#40), out of 1 resident transfer reviewed. [...]

Inspectors wroteBased on record review and interview, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program. Specifically, the facility failed to follow the directives of the PASRR Level I determination to notify the State of Alaska Division of Senior and Disability Services (SDS) for 1 resident (#4), out of 13 residents reviewed, when the resident stayed beyond their approved convalescent care period. This failed practice resulted in Resident #4 remaining in the facility without the required PASRR Level II evaluation to determine whether the resident required specialized services, which had the potential to adversely affect the resident's ability to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure the comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team (IDT) after quarterly assessments for 1 resident (#40), out of 1 resident reviewed for care plan revision. Specifically, the facility's IDT failed to review Resident #40's quarterly care plan reviews and revisions, following the resident's quarterly assessments. This failed practice placed Resident #40 at risk for changes in his/her comprehensive care plan without the involvement of individuals who have knowledge of the resident's needs, placing the resident at risk for inappropriate or subtherapeutic care interventions that could adversely affect his/her health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at a safe temperature for 2 residents (#15 and #24), out of 2 residents reviewed for reheated food. Specifically, the facility failed to ensure that food temperatures were checked after reheating food in the microwave. The facility served microwave-reheated chicken noodle soup to Resident #15 at 190.4 F (degrees Fahrenheit) and almond milk to Resident #24 at 182 F without ensuring the food and beverage had cooled to a safe temperature before being served. This failed practice placed Residents #15 and #24 at risk for scalding and burn injuries from consuming excessively hot food and beverages.

Inspectors wroteBased on record review, observation, and interview, the facility failed to establish and maintain an effective infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections for 1 resident (#43), out of 13 sampled residents reviewed for transmission-based precautions. Specifically, the facility failed to ensure appropriate infection control practices were consistently implemented for Resident #43 while the resident was being evaluated for Clostridioides difficile (C. difficile - a bacterial infection that can cause diarrhea and inflammation of the colon), including appropriate transmission-based precaution signage, appropriate hand hygiene, availability and use of an appropriate disinfectant, and staff knowledge of the precautions required. [...]

Inspectors wroteBased on record review and interview, the facility failed to immediately report an allegation of verbal abuse to the State Survey Agency in accordance with CFR (Code of Federal Regulations) S483.12 (b)(5) for 1 resident (#2), out of 4 sampled residents reviewed. Specifically, the facility failed to notify the State Survey Agency of alleged violations involving abuse no later than two hours after allegation was made. [...]

Inspectors wroteBased on record review and interview, the facility failed to respond to an allegation of verbal abuse for 1 resident (2), out of 4 sampled residents reviewed, in accordance with CFR (Code of Federal Regulations) S483.12(c). Specifically, the facility failed to:1) thoroughly investigate allegations of verbal abuse;2) prevent further potential abuse while the investigation was in progress; and3) report results of an investigation to the State Survey Agency within 5 working days of the incident to include verification of allegations and corrective actions taken. This failed practice resulted in Resident #2's unhappiness in the facility and fear of retaliation. [...]

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of the manufacturer's manual, the facility failed to conduct monthly inspections of seven of seven facility owned Hoyer (mechanical) lifts and of lifts owned by two of two (Resident (R) 2 and R6) residents with personal mechanical lifts. This failure increased the risks of accidents due to mechanical failure.

Inspectors wroteBased on interview, record review, and review of facility policy, 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 of three residents (Resident (R) 3, R1, and R5) reviewed for abuse and neglect out of a total sample of six. Failure to report injuries of unknown origin and allegations of abuse and neglect places residents at risk for continued potential abuse.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to thoroughly investigate an allegation of abuse and bruising of unknown origin for two of five residents (Resident (R) 3 and R1) reviewed for abuse and neglect out of a total sample of six. Failure to thoroughly investigate allegations of neglect and injuries of unknown origin places residents at risk for potential continued abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete skin assessments for one of six sampled residents (Resident (R) 1) whose records were reviewed. Failure to complete routine skin assessments placed residents at increased risk of alterations in skin integrity.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure one of three residents (Resident (R) 2) reviewed for the use of mechanical lifts out of a total sample of six was transferred in a safe manner, using two people as per facility policy. Failure to transfer residents in a safe manner placed R2 at risk for injury. Following the incident, the facility identified and implemented a Performance Improvement Plan (PIP) to ensure staff followed the facility's policy requiring two staff members when using a mechanical lift.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards. Specifically, the facility failed to: 1) Establish safety measures for proper cigarette disposal and the use of required adaptive devices, identified during smoking safety assessments, for residents who smoke tobacco on the facility's campus for 5 residents (#'s 9, 10, 21, 32, and 47), out of 7 total residents who smoked; 2) Complete annual smoking safety screening assessments for 4 residents (#'s 9, 21, 32, and 47), out of 7 total residents who smoked; 3) Complete smoking safety screening assessments for 3 residents (#'s 12, 25, and 54), out of 3 total residents who used electronic cigarettes (known as vapes); and 4) Secure lighters within the facility for 6 residents (#'s 9, 10, 21, 32, 47, and 53), out of 7 total residents who smoked. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure nursing staff had the appropriate skill sets to administer medications accurately for 1 resident (#8), out of 9 residents observed for medication administration. Specifically, the Licensed Nurse (LN) removed and administered a medication from a blister pack (a 30-day supply of medications in a card with bubbled packaging for individual doses of the medication) that was not labeled for the intended recipient. This failed practice placed the resident at risk for potential adverse outcomes of medication errors, or the possibility of running out of medications that were borrowed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: 1) concentrations of kitchen sanitizing solutions were maintained within acceptable parameters to ensure it adequately cleaned kitchen surfaces; and 2) concentrations of fruit and vegetable cleaning solution was maintained within acceptable parameters to ensure produce was appropriately cleaned prior to being served to residents. These failed practices created a potential for food borne illness and/or cross contamination for 57 residents who received food from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a produce wash solution dispenser was in operating condition. This failed practice placed 57 residents that received food from the kitchen at risk for foodborne illnesses and communicable diseases from subquality cleaning of fresh produce.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure one resident (#48), out 15 sampled residents, was provided care in a manner that promoted dignity and respect. Specifically, staff failed to cover the resident's buttocks and genitals, for dignity, while staff walked away to empty a urinal. This failed practice had the potential to cause the resident humiliation and shame.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure reasonable accommodation of needs, of always having a call light within reach, was maintained for 1 resident (#39), out of 15 sampled residents reviewed. This failed practice placed the resident at risk for not being able to call for help if needed.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure care plans were individualized to meet the communication needs for 1 resident (#34), out of 15 sampled residents. Specifically, the care plan failed to: 1) address how staff should communicate with this nonverbal resident; and 2) contain interventions that were individualized or resident-centered for Resident #34. This failed practice placed the resident at risk for not receiving the necessary interventions to attain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the care plan for 2 residents (#'s 47 and 54), out of 15 sampled residents. Specifically, the facility failed to update and revise the care plans to reflect: 1) Discontinuation of contact barrier precautions and antibiotic medication use for Resident #47; and 2) Initiation of anticonvulsant (medication used to prevent or control seizures) medication use and discontinuation of enteral feedings (process of delivering nutrition directly into the gastrointestinal tract, usually through a tube, for individuals who cannot eat enough by mouth but have a functioning digestive system) for Resident #54. These failed practices placed the residents at risk for not receiving appropriate and/or accurate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the development of infections. Specifically, the facility failed to ensure: 1) Suction tubing and a yankauer tip (a hard plastic handle, placed on the suction tubing, with a rounded, open tip for suctioning in a resident's mouth) remained clean and sanitary for 1 resident (#29), out of 15 sampled residents; and 2) A urinary catheter (a medical device that helps drain urine from the bladder) bag was hung in a manner to remain clean and sanitary for 1 resident (#55), out of 14 residents with catheters. These failed practices placed the residents at risk for infection which could have affected his/her overall health and wellbeing.

Inspectors wroteBased on observation and interviews, the facility failed to ensure state laws were followed regarding posting variance decisions. Specifically, the facility failed to ensure variance decisions were displayed in a conspicuous location where the posting could be readily viewed. This failed practice violated 7 Alaska Administrative Code (AAC) 10.940 and denied all residents (based on a census of 60) and resident representatives the right to the knowledge of criminal history of facility employees.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure: 1) monthly medication regimen reviews (MRR) were completed for 5 residents (#'s 2, 3, 14, 16, and 29), out of 5 residents reviewed for unnecessary medications; and 2) a physician order included all the required medication concentration parameters for 1 resident (#10), out of 14 sampled residents. These failed practices had the potential to decrease oversight of the residents' medication orders, which could have led to medication errors and adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medical products were removed and replaced from the second-floor medical emergency code cart (crash cart/emergency cart/equipment used for resuscitation). This failed practice placed residents in the facility (based on a census of 54), that had a full code status, at risk for adverse effects or complications from use of expired products during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) store food in proper sanitary condition; and 2) ensure hairnets were worn and handwashing was performed by staff handling food. These failed practices placed residents, based on a census of 54, who received food from the kitchen, at risk for foodborne illnesses and communicable disease.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure notice of the availability of the State inspection results were posted in an area of the facility that was prominent and accessible to the public. This failed practice had the potential to deny the residents (based on a census of 54) and public knowledge of the location of the most recent survey results and plans of correction the facility had put into place.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate staffing data for the 4th quarter of 2023 (July to September 2023) was reported to Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ). This failed practice potentially denied residents and/or representatives (based on census of 54), and the public, accurate staffing data when accessing the Nursing Home Compare website.