Maple Springs of Wasilla

Inspectors wroteBased on record review, observations, and interviews, the facility failed to implement fall prevention interventions for 1 resident (#49), out of 16 sampled residents. Specifically, a staff failed to ensure the resident correctly applied non-skid socks as outlined in the care plan. This failed practice placed the resident at risk for a fall and/or injuries.

Inspectors wroteBased on record review, observation, and interview, the facility failed to administer a medication through the route ordered for 1 resident (#34), out of 16 sampled residents. This failed practice created a medication error and placed the resident at risk of adverse reactions.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure infection control procedures were properly implemented in the facility for 3 residents (#s 4, 54, and 58) out of 16 sampled residents. Specifically, the facility failed to: 1) ensure Certified Nurse Assistants (CNAs) used required personal protective equipment (PPE) while caring for residents (#'s 4 and 54) who were on enhanced barrier precautions (EBP-the use of gown and gloves during high-contact resident care activities); and 2) ensure a clean environment during Resident #58's wound care. These failed practices placed the residents at risk of infection which could have affected their overall health and wellbeing.

Inspectors wroteBased on record review and interview, the facility failed to ensure the residents right to be informed, in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care and treatment recommendations were upheld. Specifically, the facility failed to ensure the Psychotropic Medication Informed Consent [and] Risk/Benefit Statement forms, used for education and consent for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior), were completed accurately, timely, and by health care providers with an original signature for 9 sampled residents (#'s 6; 8; 15; 16; 18; 28; 33; 35; and 204) and 8 unsampled residents (#'s 2; 7; 19; 25; 31; 37; 41; and 105), out of 25 residents on psychotropic medications. [...]

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure: 1) physicians completed the Physician Orders for Life-Sustaining Treatment (POLST - Physician orders that clarify life sustaining measures if needed, to include cardiopulmonary resuscitation [CPR], initial treatment orders, and medically assisted nutrition) physician order forms with residents; and 2) were signed and dated with an original signature for 9 sampled residents (#'s 3; 6; 8; 17; 28; 33; 35; 38; and 204), out of 14 sampled residents reviewed; and 35 unsampled residents (#'s 2; 4; 5; 7; 11; 14; 21; 22; 24; 25; 26; 30; 31; 32; 34; 36; 37; 39; 40; 41; 42; 45; 46; 48; 49; 103; 104; 105; 203; 205; 206; 253; 254; 303; and 304), out of 39 unsampled residents reviewed. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were accurately completed in accordance with accepted professional standards of practice. Specifically, the facility failed to ensure: 1) The Psychotropic Medication Informed Consent [and] Risk/Benefit Statement forms, used for education and consent for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior), were completed accurately, timely, and by authorized health care providers with an original signature for 9 sampled residents (#'s 6; 8; 15; 16; 18; 28; 33; 35; and 204) and 8 unsampled residents (#'s 2; 7; 19; 25; 31; 37; 41; and 105), out of 25 residents on psychotropic medications in the facility. 2) The nursing staff accurately documented the removal of a medication patch for one resident (#41) out of 25 medication administrations reviewed. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure three residents' (#6; and #28) transfer notices were sent to the Alaska Office of the State Long Term Care Ombudsman (LTCO). This failed practice had the potential to affect all residents, based on a census of 53, by: 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State (LTCO) was aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure comprehensive care plans were developed and implemented with smoking care needs for two residents (#'s 11, and 33), out of 14 sampled residents. Specifically, the facility failed to address risk factors and include specific information concerning the residents' smoking in their care plans. This failed practice had the potential to place the residents at risk for harm.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive care plans were revised to meet the changing needs of 2 residents (#'s 10 and 18), out of 14 sampled residents. Specifically, the facility failed to revise care plans to reflect: 1) the level of support needed during appointments for 1 resident (#10); 2) the interventions added for fall prevention for 1 resident (#18); and 3) the interventions trained to address behavioral/emotional needs for 1 resident (#18). These failed practices placed the residents at risk for less than the highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure two nursing staff (Certified Nursing Assistant [CNA] #3 and Licensed Nurse [LN] #7), out of 15 personnel records reviewed, had valid Cardiopulmonary Resuscitation (CPR) certificates. This failed practice placed all residents at risk for not receiving timely CPR or emergency care when needed.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents were free from accident hazards and/or received adequate supervision. Specifically, the facility failed to: 1) Ensure the care plan was followed regarding the total number of staff needed for safe bed mobility for 1 Resident (#6), out of 14 sampled residents; 2) Ensure neurological assessments, after unwitnessed falls, were conducted accurately for 1 Resident (#18), out of 14 sampled residents; and 3) Ensure 3 residents (#'s 11; 16; and 33), out of 3 residents reviewed for smoking, were assessed for safe storage of smoking paraphernalia (cigarettes and lighter or matches). These failed practices created a potential for accidents and injury to the residents.

Inspectors wroteBased on record review and interview the facility failed to complete a comprehensive admission assessment using the Resident Assessment Instrument 3.0 Minimum Data Set (MDS, a federally required nursing assessment for long term care residents) for one resident (#204), out of 14 sampled residents. This failed practice had the potential to cause inaccurate health and functional status for the resident, of which placed the resident at risk for inconsistent care.

Inspectors wroteBased on record review, observation, and interview, the facility failed to complete a comprehensive reassessment within 14 days after the Resident was diagnosed with dementia for one resident (#28) out of 14 sampled residents. This failed practice had the potential to decrease the resident's quality of life and jeopardized potential for maintaining functional independence at the highest possible level.

Inspectors wroteBased on record review and interview, the facility failed to ensure range of motion (ROM) exercises were provided to 1 resident (#6), out of 14 sampled residents. This failed practice had the potential to place the resident at risk of not receiving the necessary care and therapy to maintain his/her level of mobility.

Inspectors wroteBased on record review and interview, the facility failed to review the drug regimen for 1 resident (#18), out of 14 sampled residents, for adequate parameters of a medication dose range order (orders in which there are dosing amount options over a prescribed range). This failed practice had the potential to expose the resident to unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen equipment was in a safe operating condition. Specifically, the facility failed to ensure the walk-in freezer door's gasket (a flexible rubber strip that runs along the edge of the door to create an airtight seal) was without compromise. This failed practice placed all residents (based on a census of 53) at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food under proper sanitation and food handling practices in the central kitchen. This failed practice placed all residents (based on a census of 55) at risk for foodborne illnesses and communicable disease.

Inspectors wroteBased on record review and interview, the facility failed to ensure State Laws were followed. Specifically, the facility failed to ensure individuals employed by the facility had a valid criminal history background check for 4 employees: 1) Certified Nursing Assistant (CNA) #4; 2) Neighborhood Helper (NH) #1; 3) [NAME] #2; and 4) Housekeeper #1. This failed practice violated State background check Alaska Administrative Code (AAC) and placed all residents (based on a census of 55) at risk for receiving care and services from individuals with barrier crimes and no valid variance.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure 5 residents (#'s 1; 24; 50; 155; and 305), out of 16 sampled residents, were assessed to determine safety prior to self-administration of medications. This failed practice placed the residents at risk of medication errors, and potential drug interactions.

Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS (Minimum Data Set- A federally required nursing assessment) accurately reflected the resident's status at the time of assessment. Specifically, the facility failed to: 1) complete a discharge assessment for 1 unsampled resident (#3), out of 1 reviewed for resident assessment; 2) assess for hearing aids for 2 residents (#'s 2 and 37), out of 16 sampled residents; 3) ensure oxygen therapy and/or CPAP (continuous positive airway pressure) use were identified for 2 residents (#'s 37 and 50), out of 16 sampled residents; and 4) ensure a broken denture was identified for 1 resident (#304), out of 16 sampled residents. These failed practices placed the residents at risk for receiving an inaccurate care plan, interventions, and recieving less than optimal care.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure care plans were individualized to meet the medical and psychosocial needs for 6 residents (#'s 2; 13; 34; 37; 50; and 304) out of 16 sampled residents. This failed practice placed the residents at risk for not receiving necessary services to address their individual needs.

Inspectors wroteBased on record review, observation, and interview, the facility failed ensure respiratory care was consistent with professional standards of practice for 3 residents (#'s 37; 50; and 304), out of 16 sampled residents. This failure had the potential to place the residents at risk for inconsistent care, and potential respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure patient care equipment was monitored to ensure it was in a safe operating condition. Specifically, the facility failed to: 1) complete daily maintenance checks on 2 emergency code carts (emergency cart/equipment used for resuscitation); and 2) maintain and monitor a unit freezer. This failed practice: 1) placed residents residing in the facility, that were a full code, at risk for adverse outcomes in the event of malfunctioning emergency equipment, and 2) placed residents at risk for receiving food not stored at appropriate temperatures which increased the chance of food borne illnesses.

Inspectors wroteBased on record review and interview, the facility failed to obtain informed consent for psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants that would have affected behavior, mood, thoughts, or perception) prior to use for 1 resident (#1), out of 5 sampled residents for unnecessary medications. This failed practice denied the resident the right to consent to medications and be informed of the risk and benefits for medication use.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident rights to self-determination were honored. Specifically, the facility failed to provide a method for storing perishable food brought in by family or visitors. This failed practice denied the residents the right to store perishable food brought into the facility.

Inspectors wroteBased on record review and interview, the facility failed to resolve a grievance for 1 resident (#24) out of 16 sampled residents. Specifically, the resident's complaint was not fully resolved, and the resident did not receive a written grievance decision which included the steps taken to investigate the grievance and a summary of pertinent finding or conclusions regarding the resident's concerns. This failed practice denied the resident information regarding a resolution of the grievance.

Inspectors wroteBased on record review, interview, observation and document review, the facility failed to ensure safety equipment was checked per manufacturer's instructions for 1 resident (#36) out of 1 resident sampled for wandering. Specifically, the wanderguard tag device (worn by the resident to alert the facility if the resident eloped) was checked monthly instead of weekly. This failed practice had the potential to cause harm if the resident wandered outside during a time the equipment was not functioning. Record review from 3/20-24/23 revealed Resident #36 was admitted to the facility with diagnoses that included dementia, depression, and diabetes. During an interview on 3/20/23 at 2:47 PM, Resident #36's POA (power of attorney) stated he/she was called by the facility in the past because the Resident had wandered outside. The POA stated the Resident now has a wanderguard device in place. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure 1 resident (#8) out of 2 residents sampled with a foley catheter (a hollow tube inserted into the bladder to drain urine) was assessed timely for discontinuation of the catheter. This failed practice had the potential to keep the device in place for longer than clinically necessary and increased the potential for the resident to develop a urinary tract infection.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure administration of enteral nutrition (a liquid diet delivered by way of tube feeding) was free of possible complications for 1 resident (#29), out of 2 residents observed for enteral nutrition. Specifically, the facility failed to ensure the resident's head of the bed was positioned no lower than 30 degrees in elevation during enteral feedings. This failed practice had the potential to cause aspiration (liquid entering the lungs).

Inspectors wroteBased on interview and observation, the facility failed to ensure reconciliation of a controlled drug (narcotic medication for pain) was accurate. Specifically, the facility failed to ensure liquid narcotic medication volume was accurately reconciled for 1 resident out of 8 residents sampled during medication cart review. This failed practice had the potential for inaccurate narcotic reconciliation.

Inspectors wroteBased on record review and interview, the facility failed to ensure duplicative medications ordered for constipation, were written with adequate indications for use for 1 resident (#37), out of 16 sampled residents. Specifically, the facility failed to ensure: 1) clear guidance on when to use Senna (medication used for constipation) in the bowel protocol; and 2) the as needed bowel medication orders included sequence for use. These failed practices had the potential to inadequately medicate the resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs used in the facility were labeled in accordance with accepted professional practices. Specifically, the facility failed to ensure the label on the Melatonin (a supplement used for insomnia) blister pack for 1 discharged resident was not re-labeled as stock medication and put into use within 1 medication cart out of 3 medication carts observed. This failed practice placed all residents that received this medication from this cart at risk of misuse of prescribed medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure menus were accurate for 2 residents (#s 37 and 304), out of 16 sampled residents. This failed practice caused the residents to receive an incorrect diet which could have affected their overall health and wellbeing.