Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wasilla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Springs Of Palmer | 7.3 mi | — | 0 | 0 |
| Centennial Post Acute | 27.6 mi | — | 9 | 0 |
| Polaris Transitional Care | 29.4 mi | — | 10 | 0 |
| Polaris Extended Care | 29.4 mi | — | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Maple Springs Of Wasilla.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.