Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Ridge Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and impulsivity accessed an unlocked, unattended med cart after an RN left it unsecured, despite a care plan intervention to keep the nurse positioned so the resident could not access medications. The resident removed and ingested multiple blister packs of medications not prescribed to him, then developed AMS, confusion, and an unsteady gait. He was sent to the ED and admitted to the MICU with severe hyponatremia.
A resident with HIV, paranoid schizophrenia, and schizoaffective disorder accessed an unlocked and unattended med cart left in a hallway, removed multiple blister packs, and self-administered medications without staff supervision. The resident was later found with altered mental status, confusion, decreased awareness, and an unsteady gait, and EMS transferred the resident to the ED. Hospital records documented empty blister packs for several meds, and staff interviews confirmed the RN left the cart unlocked and unattended.
Missing Ombudsman Notifications for Hospital Transfers: The facility failed to document that written transfer notices were sent to the Ombudsman for 3 residents who had multiple hospital transfers. One resident had repeated EMS transfers for severe pain, nausea/vomiting, and hyperglycemia; another had transfers for yelling, respiratory distress, and a fall with laceration; and a third had transfers for abdominal pain, vomiting, and dark red stool. The ADM stated discharge summaries were completed before hospital transfers, but he could not locate Ombudsman notifications, though he said it was part of the process.
A resident with severely impaired cognition accessed an unlocked, unattended med cart, removed multiple blister packs, self-administered medications, and later developed AMS and hyponatremia requiring EMS transfer and MICU care. The facility also documented repeated falls for residents with severe cognitive impairment and mobility issues, but the responses were often limited to repeating the same care plan interventions, reviewing the plan, or noting that no new interventions were found after subsequent falls.
A resident with radiculopathy and major depressive disorder had a pharmacist MRR note stating that sodium fluoride toothpaste ordered PRN should be changed to scheduled daily use. The facility policy required staff to act on all MRR recommendations, but the recommendation was not documented and acted upon for months, and the RDCS stated the DON was responsible for follow-up on pharmacy recommendations and that the previous DON was not following policy.
Failure to Obtain Ordered Laboratory Monitoring: Two residents did not have ordered lab monitoring completed or documented in the medical record. One resident with schizophrenia and CHF lacked multiple monthly CBC results related to Clozaril use, while another resident with cerebral infarction and mood/sleep disorders did not have February routine labs, including CBC, CMP, valproic acid level, and lipid panel, despite standing orders. The RDCS stated that missing results were not found in the EMR and that the May labs were intended to replace the missed February labs.
Labs were obtained without documented orders for two residents. One resident with cerebral infarction, anxiety, adjustment disorder, and insomnia had CBC w/diff and CMP results reviewed by the provider, but no lab order was found, and the RDCS said routine labs had been missed and the May labs were meant to replace labs due earlier. Another resident with anoxic brain damage, convulsions, and DM with neuropathy had HgbA1C, CMP, CBC w/diff, prolactin, valproic acid, and lipid panel results in the chart, but no physician order was located; the RDCS stated a physician order is needed for labs.
Missing Monthly CBC Results in Resident Record: A resident with schizophrenia, CHF, and an intracranial injury had active physician orders for monthly CBCs related to clozaril use, but multiple monthly CBC results were not filed in the EMR. During interview, the RDCS stated lab results should be uploaded under the Documents or Results tab, and if they were not there, the facility likely did not have a record that the labs were completed.
Incomplete and inaccurate resident medical records were identified for two residents. One resident's MDS listed schizophrenia even though the record did not support a PASRR level 2 for that diagnosis, and the RDCS stated the resident had no mental health issues. Another resident had an order for bromocriptine for DM despite no DM diagnosis in the record; an LPN and the RDCS both confirmed the resident did not have DM, and the RDCS was unsure why the medication was being given.
Failure to implement EBP for two residents with chronic wounds and wound-related care needs. One resident with a chronic foot ulcer and another resident with multiple open skin areas and chronic leg, shoulder, and buttock wounds had no EBP signage or PPE available in their rooms, and staff interviews showed inconsistent understanding of the EBP orders. CNAs reported providing care with only gloves or without gowns, while the RDCS confirmed both residents should have been on EBP with gown and glove use for high-contact direct care.
The facility did not employ a full-time clinically qualified dietitian or a certified dietary manager to direct nutrition services. The current DM had not completed required training or certifications and confirmed that the RD was not full-time. The ADM was aware of these deficiencies when the DM was moved into the position after the previous DM resigned.
The facility did not ensure that laboratory results for several residents were filed in their medical records as required. For four residents with complex medical conditions and multiple lab orders, the actual lab reports were missing from their clinical files, despite documentation that labs were ordered and sometimes reviewed. This deficiency was confirmed through record review and staff interviews, revealing a breakdown in the process for uploading lab results.
A resident with multiple complex medical conditions was documented as full code without a completed POLST or Advance Directive in the medical record. Required documentation and processes for determining and recording advance directive preferences were not followed, leaving the resident's code status and treatment wishes unclear.
A resident reported a missing wallet containing identification and Medicaid card and requested assistance from the Resident Advocate, who did not follow up or document the grievance investigation as required by facility policy. No evidence of prompt resolution or investigation was found in the grievance records.
A resident with a history of behavioral issues and multiple medical conditions was prescribed Trazodone and Depakote, but the facility failed to document a rationale for not attempting a gradual dose reduction (GDR) for Trazodone and did not attempt or document a GDR or clinical contraindication for Depakote. Staff interviews confirmed the medications were used for behaviors, but required documentation and rationale were missing.
Two residents were transferred to hospitals without proper documentation in their medical records of what information was sent to the receiving providers. Despite staff stating that they typically notify providers and send necessary paperwork, there was no record of transfer/discharge summaries or details such as practitioner contact, advanced directives, or care plan goals being communicated, resulting in incomplete transitions of care.
A resident with multiple chronic conditions experienced ongoing constipation, with documented periods of up to six days without a bowel movement. Although there were physician orders for Milk of Magnesia to treat constipation, the medication was not administered, and the care plan only addressed urinary elimination, omitting bowel elimination needs. The DON confirmed the care plan did not include interventions for constipation.
A resident with multiple chronic conditions experienced constipation that was not managed according to physician orders and the facility's bowel protocol. Despite documented periods of no bowel movement and standing orders for Milk of Magnesia (MOM) to be administered after three days without a BM, the medication was not given, and there was no documentation of administration, refusal, or follow-up interventions. Staff interviews revealed uncertainty about protocol implementation, and the resident's care plan did not address bowel management.
A resident with a history of heart disease and arthritis reported severe pain and requested more effective pain relief, but staff did not provide pain medication, alternative analgesics, or nonpharmaceutical interventions. Despite physician orders for acetaminophen and topical analgesics, there was no documentation that these were offered or administered, and the resident continued to report pain without relief. Documentation of pain assessments, interventions, and refusals was also lacking.
Surveyors found that an LPN and the DON did not ensure multi-use vials of Humalog and aplisol were properly labeled with open or discard dates. A resident's Humalog vial had an unclear date, and the aplisol vial lacked any labeling, both remaining available for use.
A resident with multiple complex diagnoses had a medication order incorrectly entered into the medical record, with hydroxyurea documented instead of hydroxyzine, and no corresponding diagnosis for sickle cell disease. Hydroxyzine was present in the medication cart, but there was no active order for it in the record. Interviews with an LPN and the DON confirmed that medication orders should be verified, but the error led to incomplete and inaccurate documentation.
A resident with multiple wounds and a PICC line did not have enhanced barrier precautions in place, and staff were unaware of the need for such precautions. During a meal, a plate guard that had fallen to the floor was reused without cleaning, contrary to facility expectations. These lapses resulted in a failure to maintain proper infection prevention and control practices.
A resident with multiple medical conditions experienced two incidents—elopement and an allegation of sexual abuse—where facility documentation failed to include the date APS was notified, despite forms indicating notification occurred. The administrator confirmed no further documentation was available to verify timely reporting.
A resident with severe cognitive impairment and a high risk for elopement was able to leave the facility unsupervised on two occasions due to inadequate supervision and unsecured exit points. Despite orders for a wander guard and frequent monitoring, the resident exited through a gate left open by visitors and, in another instance, through a side gate while the wander guard was attached to a wheelchair. Staff did not consistently check all areas when alarms sounded, and exit points were not always secured, resulting in the resident being found off facility grounds by police.
Unsecured Medication Cart Allowed Resident Access to Unprescribed Medications
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and impulsivity from neglect when a medication cart was left unlocked and unattended. The resident had diagnoses including HIV, paranoid schizophrenia, and schizoaffective disorder, and a Quarterly MDS showed a BIMS score of 0, indicating severely impaired cognition. The resident’s care plan included an intervention added on 9/17/25 stating that the resident was extremely impulsive and that the medication cart should be positioned so the nurse’s back was never toward residents. On 3/4/26, an RN left the medication cart unlocked and unattended, allowing the resident to access the cart and remove multiple medication blister packs. Staff later found medication cards in the resident’s room, and the resident was noted to have altered mental status, confusion, decreased awareness, and an unsteady gait. The DON and provider were notified, EMS was activated, and the resident was transferred to the emergency department for further evaluation and treatment. Hospital records showed the resident had ingested medications not prescribed to him, including Abilify, Eliquis, desmopressin, atorvastatin, metoprolol XL, doxycycline, melatonin, and Zofran. He was admitted to the MICU with hyponatremia, initially 117, and increased urine output related to the ingestion. The facility’s incident review identified that the medication cart had been left unlocked and unattended, and the RDCS stated the RN’s employment was terminated for violating facility policy regarding medication cart security.
Unsecured Medication Cart Allowed Resident Access to Blister Packs
Penalty
Summary
The facility failed to store medications in a locked compartment and limit access to authorized staff only. During the incident involving Resident 32, the medication cart was left unlocked and unattended in a public hallway, allowing the resident to access multiple medication blister packs and self-administer medications without staff supervision. The report states this resulted in harm. Resident 32 was admitted and readmitted to the facility with diagnoses including human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder. The resident’s record shows that on 3/4/25 the resident accessed the unlocked medication cart, obtained medication cards and pills, and was later found with medication cards in the room. The event note described altered mental status, confusion, decreased level of awareness, and an unsteady gait, and EMS was activated for transfer to the emergency department. The inpatient admission notes from the hospital documented that the resident arrived by EMS after empty blister packs were found for multiple medications, including abilify, Eliquis, desmopressin, atorvastatin, metoprolol XL, doxycycline, melatonin, and zofran. The hospital record stated it was unclear how much medication was taken, and the resident was admitted to the MICU for management of hyponatremia. Interviews with facility staff and the Regional Director of Clinical Services confirmed that the RN had left the medication cart unlocked and unattended and that the resident removed multiple blister packs from the cart.
Missing Ombudsman Notifications for Hospital Transfers
Penalty
Summary
The facility failed to ensure that transfer and discharge documentation was properly completed and that required notifications were sent to the Office of the State Long-Term Care Ombudsman for residents who were transferred to the hospital. For 3 of 19 residents reviewed, the record did not contain evidence that a copy of the written transfer notice had been sent to the Ombudsman at the time of transfer. Resident 20 was admitted and readmitted with diagnoses including acute respiratory failure with hypoxia, schizophrenia, and acquired absence of lung. The record showed hospital transfers on 4/24/26, when the resident complained of 10/10 burning stomach pain, began vomiting, reported dark red stool, and left via EMS, and on 5/11/26, when a discharge summary documented transfer to a hospital. During review of the medical record from 6/1/26 through 6/4/26, there was no documentation that the facility sent a copy of the written transfer notice to the Ombudsman. Resident 40 was admitted and readmitted with diagnoses including unspecified intracranial injury without loss of consciousness and dementia with mood disturbance. The record showed multiple hospital transfers, including 10/20/25 when the resident was yelling throughout the night and was transported via EMS after staff called 911, 11/13/25 for labored breathing with rhonchi, wheezing, and decreased responsiveness, and 11/25/25 after falling from a wheelchair and sustaining a laceration above the left eyebrow. During review of the medical record from 6/1/26 through 6/4/26, there was no documentation that the facility sent a copy of the written transfer notice to the Ombudsman. Resident 2 was admitted with diagnoses including type 2 diabetes, unspecified dementia, major depressive disorder, borderline personality disorder, and sepsis. The record documented numerous hospital transfers for pain, nausea and vomiting, hyperglycemia, urinary symptoms, and other complaints, including several instances where the resident independently called 911 and was transported by EMS. During review of the medical record from 6/1/26 through 6/4/26, there was no documentation that the facility sent a copy of the written transfer notice to the Ombudsman. The Administrator stated that staff completed a discharge summary before residents were transferred to the hospital and that he was unable to locate any notifications made to the Ombudsman regarding hospital transfers, although he stated it was part of their process.
Unsecured Medication Cart and Repeated Falls Without New Interventions
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. One resident with severely impaired cognition, including a BIMS score of 0 and diagnoses of HIV, paranoid schizophrenia, and schizoaffective disorder, accessed an unlocked and unattended medication cart. Staff later found multiple medication blister packs in the resident’s room, and the resident had self-administered medications without supervision. The resident developed altered mental status, confusion, decreased level of awareness, and an unsteady gait, and EMS was activated for transfer to the emergency department. Hospital records stated the resident had empty blister packs for multiple medications and was admitted to the MICU with hyponatremia. The record also showed repeated falls for another resident with severely impaired cognition and diagnoses including unspecified intracranial injury without loss of consciousness and dementia with mood disturbance. The resident’s chart documented numerous falls over several months, including falls from the bed, wheelchair, bathroom area, dining room, and floor near the bed, with injuries such as forehead bruising, eyebrow lacerations, and head wounds requiring EMS or hospital transfer. Several event notes documented that after these falls, the interventions were limited to reviewing the care plan, maintaining the current plan of care, or noting that no interventions were located. Some notes repeated the same interventions such as asking the resident to use the call light, anticipating needs, or referring the resident for wheelchair evaluation. A third resident with a history of traumatic hemorrhage of the cerebrum, dementia, impaired gait and balance, poor muscle control, seizures, cataracts, myopia, refusal of care, and noncompliance also had multiple falls. The record documented unwitnessed falls in the bathroom, beside the wheelchair, between the bed and wheelchair, and while transferring, with injuries including a large open wound above the eye and other abrasions. Interventions after these falls were repeated, including educating the resident to ask for help, educating staff to anticipate needs, and assessing for pain or injury. Interviews with CNA, LPN, the RDCS, and the Administrator confirmed that the resident had a history of falls, that staff were aware of the repeated events, and that repeated interventions were used rather than unique interventions for each fall.
Pharmacist Recommendation Not Addressed for Scheduled Dental Medication
Penalty
Summary
The facility failed to ensure that the licensed pharmacist’s monthly drug regimen review recommendations were documented and acted upon for 1 of 19 residents reviewed. Resident 13 was admitted and later readmitted with diagnoses including radiculopathy of the lumbosacral region and major depressive disorder. During review of the medical record, the pharmacist’s 3/16/26 recommendation stated that the resident had an order for sodium fluoride toothpaste to be used as needed, but that it was recommended for daily use and should be changed to a scheduled daily order instead of as needed. The facility’s Medication Regimen Review Policy, implemented on 4/11/25, stated that facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Record review showed that on 2/10/26, Sodium Fluoride Gel 1.1% 1 application dental every 12 hours as needed for sensitivity was started and discontinued on 6/2/26, and on 6/3/26, Sodium Fluoride Gel 1.1% 1 application dental every day shift for dental care was started. On 6/4/26, the RDCS stated that the DON was responsible for follow-up on pharmacist monthly recommendations, including updating physician orders to reflect the recommendation, and stated that the previous DON was not following the facility’s policy regarding pharmacy recommendations.
Failure to Obtain Ordered Laboratory Monitoring
Penalty
Summary
Timely, quality laboratory services were not provided or obtained to meet resident needs for 2 of 19 sampled residents. Resident 12, who had diagnoses including schizophrenia, chronic diastolic congestive heart failure, and unspecified intracranial injury, had a physician order for monthly CBC monitoring related to Clozaril use. Although an order dated 3/6/26 remained active during the review period, the medical record did not contain monthly CBC results for June 2025, July 2025, August 2025, February 2026, April 2026, and May 2026. The Regional Director of Clinical Services stated that lab results should be uploaded in the electronic medical record and that if they were not found in the Documents or Results tabs, it was likely the facility did not have a record that the labs were completed. Resident 27, who had diagnoses including cerebral infarction, generalized anxiety disorder, adjustment disorder with depressed mood, and insomnia, had standing orders for routine labs including CBC, CMP, valproic acid level every 6 months in February and August, and lipid panel in February. The medical record did not contain the February 2026 lab results. During interview, the Regional Director of Clinical Services stated that the resident's valproic acid level was drawn on 5/28/26, and later stated that those May 2026 labs were supposed to have been drawn in February 2026. The RDCS also stated she had audited residents and found that many were not getting routine labs drawn, and there was no progress note documenting that the previous DON contacted the medical provider regarding the missed February labs.
Labs Obtained Without Documented Orders
Penalty
Summary
The facility failed to obtain laboratory services only when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist for 2 of 19 sampled residents. For Resident 27, who was admitted with diagnoses including cerebral infarction, generalized anxiety disorder, adjustment disorder with depressed mood, and insomnia, a health status note documented that CBC with differential and CMP results were received and reviewed by the provider, but no lab order was located in the medical record. The Regional Director of Clinical Services stated there were standing orders for routine labs and that an audit showed many residents were not getting routine labs drawn. She also stated that Resident 27 had not had labs drawn in February and that the labs drawn in May 2026 were supposed to be the labs that needed to be drawn in February 2026, but there was no progress note documenting that the previous DON contacted the medical provider. For Resident 19, who was admitted with diagnoses including anoxic brain damage, unspecified convulsions, and diabetes mellitus due to underlying condition with diabetic neuropathy, laboratory results in the chart showed HgbA1C, CMP, CBC with differential, prolactin, valproic acid level, and lipid panel were collected, but no physician order was found in the medical record. During interview, the Regional Director of Clinical Services stated that a physician's order is needed to draw labs and that she was unable to find an order for the labs drawn for Resident 19. The record review and staff interviews showed that these laboratory tests were obtained without documented orders for both residents.
Missing Monthly CBC Results in Resident Record
Penalty
Summary
Keep complete, dated laboratory records in the resident's record was not met for 1 of 19 sampled residents when the facility did not ensure that ordered CBC laboratory results were filed in the resident's clinical record. Resident 12 was admitted and later readmitted with diagnoses including schizophrenia, chronic diastolic congestive heart failure, and unspecified intracranial injury. The resident had physician orders for monthly CBCs related to clozaril use, first dated 9/29/25 and later continued on 3/6/26, but the medical record reviewed from 6/1/26 through 6/4/26 did not contain monthly CBC results for June 2025, July 2025, August 2025, February 2026, April 2026, and May 2026. During interview, the Regional Director of Clinical Services stated that lab results should be uploaded under the Documents tab or Results tab in the electronic medical record, and if they were not found there, it was likely the facility did not have a record that the labs were completed.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
The facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized. For one resident, the Minimum Data Set documented a diagnosis of schizophrenia even though the medical record did not contain a PASRR level 2 with that diagnosis. During interview, the RDCS stated the resident had been screened out for PASRR 2 because he did not have any mental health issues and said the schizophrenia diagnosis would have to be removed from the MDS because she was unable to remove it. For another resident, the physician's orders included Bromocriptine Mesylate Oral Tablet 2.5 mg, ordered as 20 mg by mouth two times a day for diabetes mellitus, but the resident did not have a diagnosis of diabetes mellitus. An LPN stated the resident did not have diabetes and did not take any diabetes medications. The RDCS also stated the resident did not have a diagnosis of diabetes mellitus and was unsure why he was taking bromocriptine, then later stated the resident was admitted with the medication for diabetes and she would continue to look into why he was taking it.
Failure to Implement EBP for Residents With Chronic Wounds
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. For Resident 2, who was admitted with diagnoses including a non-pressure chronic foot ulcer, sepsis, and acquired absence of the right foot, an observation and interview found no Enhanced Barrier Precautions (EBP) signage or PPE available in the room. The resident had a wrapped right foot wound and stated that staff assisted with showering without wearing a gown. The physician order in the record directed EBP for high direct care contact activities due to wounds, but a CNA stated the resident was not on EBP and that a gown was not worn during care. An LPN stated EBP was only needed when the dressing was changed at the podiatrist's office, while the RDCS stated the resident should have been on EBP with gown and gloves for high contact care and signage on the door. For Resident 27, who had diagnoses including venous insufficiency and chronic ulcers of both lower legs, observation showed swollen legs with red marks and open areas, red marks and scabs on the upper left arm and shoulder, and bleeding from a scratch behind the right ear and neck. There were no visible bandages on the open skin areas, and no EBP signage or PPE was available in the room. The record included wound care orders for the left leg, left shoulder, and right buttock, along with an EBP order for high-contact direct care activities related to wounds. A CNA stated the resident was incontinent, required a Hoyer lift, and that she only wore gloves when assisting him. The RDCS stated the resident had chronic wounds and an active EBP order and should have EBP signage, and another CNA stated gown and gloves were needed when caring for the resident.
Failure to Employ Qualified Nutrition Services Director
Penalty
Summary
The facility failed to employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. During an initial walk-through of the kitchen, the Dietary Manager (DM) stated that he had not completed the required training to serve in his role and had only been working as DM for two months. The DM also confirmed that the Registered Dietitian (RD) did not work at the facility full-time and that he was in the process of obtaining necessary certifications. In a follow-up interview, the DM reiterated that he was scheduled to take his ServSafe test and would soon begin the Certified Dietary Manager course. The Administrator acknowledged awareness that the DM was not certified and had assumed the position after the previous DM resigned.
Failure to Maintain Complete Laboratory Records in Resident Files
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of several residents. For four out of fourteen sampled residents, laboratory results for ordered tests were not filed in their medical records. Specifically, one resident with a history of cerebral infarction, hemiplegia, dysphagia, and hypertension had a physician order for a Prothrombin Time (PT) and International Normalized Ratio (INR) lab draw, but the results were not present in the medical record. The laboratory results were only provided later upon request. The Administrator confirmed that the process required the DON to upload lab results into the medical record within a week, but this was not done for the resident in question. Additional residents were also affected by this deficiency. One resident with respiratory failure, dementia, and muscle weakness had orders for a Vitamin B12, Folate, and Iron panel, but no results were found in the record. Another resident with diabetes, chronic kidney disease, and a history of traumatic amputation had orders for a Basic Metabolic Panel and magnesium level, but again, no results were present. A fourth resident with intracranial injury, diabetes, and mood disorders had multiple lab orders, including a complete blood count and metabolic panels, with no corresponding results in the medical record. In each case, documentation indicated that labs were ordered and sometimes reviewed, but the actual laboratory reports were missing from the residents' clinical records.
Failure to Document Advance Directive and POLST Status
Penalty
Summary
A deficiency occurred when a resident was documented as full code in their medical record without having a completed Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive on file. The resident, who had multiple significant diagnoses including acute respiratory failure with hypoxia, chest pain, pleural effusion, COPD, asthma, atrial fibrillation, type 2 diabetes with complications, secondary hypertension, and shortness of breath, was admitted and readmitted to the facility. Despite the facility's policy requiring determination and documentation of advance directives upon admission, the resident's medical record lacked both a POLST and an Advance Directive, and the POLST status was left blank in the admission progress note. Interviews with the DON and Administrator confirmed that the required POLST form could not be located in the resident's record. The DON stated that completed POLST forms are to be turned in to her and then given to the Medical Director for signature, with monthly audits by the Resident Advocate. However, for this resident, the process was not completed as required, resulting in the absence of critical documentation regarding the resident's code status and advance directive preferences.
Failure to Promptly Resolve and Document Resident Grievance Regarding Missing Property
Penalty
Summary
A resident with a history of schizophrenia, tremor, stimulant abuse, COPD, peripheral vascular disease, and hypertension reported that his wallet containing identification and Medicaid card was missing. The resident informed the Resident Advocate (RA) and was told assistance would be provided to obtain new identification, but the resident stated that the RA never followed up. Review of the resident's personal inventory confirmed the wallet was previously documented, but the contents were not listed. Progress notes indicated the wallet was reported stolen, and the RA acknowledged the need to replace the wallet and obtain a new ID, but there was no documentation that this was completed. Further review of the facility's grievance binder revealed no record of a grievance or investigation related to the missing wallet and identification cards for this resident. The facility's grievance policy requires prompt efforts to resolve grievances and mandates documentation of the investigation and resolution, but no such evidence was maintained. The RA confirmed that a grievance investigation should have been initiated and documented, but none was found for this incident.
Failure to Document and Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including cerebral infarction, cognitive communication deficit, hemiplegia, hemiparesis, dysphagia, aphasia, and hypertension, was not provided with appropriate gradual dose reductions (GDR) or behavioral interventions for psychotropic medications as required. The resident had physician orders for Trazodone for insomnia and Divalproex Sodium (Depakote) for increased behaviors. Documentation showed that a clinical contraindication form for GDR of Trazodone was completed, but the section specifying the reason for the contraindication was left blank. There was no documentation of an attempted GDR or a clinical contraindication for the use of Divalproex Sodium. Interviews with staff revealed that the resident exhibited behaviors such as impatience, yelling, and a history of physical and verbal aggression, which were being monitored. The Divalproex was reportedly used for these behaviors, but no GDR attempt or clinical contraindication was documented. The process for GDR and documentation was discussed among staff, but the required rationale for not attempting a GDR, particularly for Divalproex, was not provided in the resident's record.
Failure to Document and Communicate Required Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that the transfer or discharge of two residents was properly documented in their medical records, and that all required information was communicated to the receiving provider. For both residents, there was no documentation of a transfer or discharge summary, nor was there evidence of what information was sent to the receiving provider at the time of transfer. This included missing details such as contact information for the practitioner responsible for the resident's care, resident representative contact information, advanced directive information, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary information to ensure a safe and effective transition. One resident with diagnoses including HIV, anxiety disorder, schizophrenia, and hepatitis C was transferred to a hospital after calling 911 due to complaints of brain pain, but the medical record lacked documentation of what information was provided to the hospital. Another resident with multiple complex conditions, including diabetes, chronic kidney disease, traumatic amputation, bipolar disorder, and suicidal ideations, was transferred to the hospital on two occasions due to acute medical changes, but again, the medical record did not contain documentation of a transfer/discharge summary or what information was sent to the receiving provider. Interviews with staff confirmed that while there was a process for notifying providers and sending documentation, it was not consistently documented in the residents' records.
Failure to Address Bowel Elimination in Resident Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically regarding bowel elimination. The resident, who had multiple diagnoses including schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, and peripheral vascular disease, reported experiencing constipation over the previous two months, with extended periods without a bowel movement. Medical records confirmed physician orders for Milk of Magnesia to treat constipation, but the medication was not administered during the month reviewed. Documentation showed the resident went up to six days without a bowel movement on one occasion and three days on another within a 30-day period. The resident's care plan, initially created for ADL self-care performance deficits related to schizophrenia, only addressed urinary elimination and did not include any interventions or monitoring for bowel elimination or constipation. The care plan's toileting focus area had not been updated to reflect the resident's bowel elimination needs, despite evidence of ongoing constipation and physician orders for treatment. The DON confirmed that the care plan only addressed urinary elimination and not bowel elimination.
Failure to Follow Bowel Protocol for Resident with Constipation
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, and peripheral vascular disease, experienced episodes of constipation that were not managed according to the facility's established bowel protocol. The resident reported experiencing constipation over the previous two months and indicated that he had gone extended periods without a bowel movement. Despite having physician orders for Milk of Magnesia (MOM) to be administered as needed for constipation, and a specific order to administer MOM on the third day without a bowel movement, the medication was not given during the month in question, as documented in the Medication Administration Record (MAR). Review of the resident's bowel elimination records showed multiple instances where the resident went three or more days without a bowel movement, including a six-day period and a three-day period. The facility's bowel protocol required staff to initiate treatment with MOM after three days without a bowel movement, followed by additional interventions if the initial treatment was ineffective. However, there was no documentation that the protocol was followed, that MOM was administered or refused, or that subsequent steps were taken as required by the protocol. Interviews with facility staff, including an LPN, a CNA, and the DON, revealed a lack of clarity regarding the location and implementation of the bowel protocol. The DON confirmed that the protocol should have been initiated and that documentation of administration or refusal should have been present in the MAR or nurse progress notes. The resident's care plan also did not address bowel elimination patterns or treatment for constipation, and there was no evidence that the required interventions were provided or documented during the periods of constipation.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency was identified when a resident with a history of atherosclerotic heart disease, arthritis, and a childhood neck injury reported significant pain to facility staff. The resident expressed that he was experiencing severe neck and back pain, requested to go to the hospital, and stated that his current pain management regimen of two Tylenol was ineffective. Despite these complaints, the resident was not provided with any pain medication, alternative pain relievers, or nonpharmaceutical pain interventions at the time of his request. Staff responses included relaying the complaint to a nurse, who indicated she would contact the Medical Director, and instructing the resident to rest, but no immediate pain relief measures were implemented. Review of the resident's care plan revealed it was focused on headache pain and included interventions such as medication and rest, anticipating pain relief needs, and documenting pain history and management. The care plan also noted the resident's preference for Tylenol, but did not address his arthritis or neck pain specifically. The resident's recent pain assessment documented frequent pain, with significant interference in sleep and activities, and a high pain score. Orders for acetaminophen and topical analgesics were present, but there was no documentation that these were offered or administered during the pain episode in question, nor was there documentation of refusal. Interviews with the resident confirmed that he had not received any pain relief or intervention following his complaints. The DON stated that the Medical Director was contacted, but the response was delayed by several hours, and there was no evidence of alternative pain management strategies being discussed or implemented. Documentation was lacking regarding pain assessments, interventions offered, and resident refusals, contributing to the failure to provide appropriate pain management as required.
Failure to Properly Label Multi-Use Medication Vials
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles, specifically regarding the inclusion of expiration, open, or discard dates. During an inspection of the medication fridge at the nurses station with an LPN, an open multi-use vial of Humalog was found with a date on the box, but the LPN was unsure if it represented the open or discard date. This vial was available for use and belonged to a resident. Additionally, an open multi-use vial of aplisol was present in the fridge without any open or discard date labeled. The DON confirmed that multi-use vials are typically labeled with an open date and that both Humalog and aplisol are considered good for 30 days after opening, but this practice was not followed for the vials in question.
Incorrect Medication Order Entry and Incomplete Medical Record Documentation
Penalty
Summary
A deficiency was identified when a resident's medication order was incorrectly entered into the medical record. The resident, who had a complex medical history including type 1 diabetes mellitus, generalized anxiety disorder, chronic kidney disease stage 3, traumatic amputation of toes, bipolar disorder, and suicidal ideations, was admitted and readmitted to the facility. During a review of the resident's records, it was found that a physician's order for Hydroxyurea 25 mg by mouth every 12 hours as needed for anti-anxiety was documented, despite no diagnosis of sickle cell disease being present in the resident's record. Additionally, a nursing progress note indicated a verbal order to restart hydroxyzine 25 mg by mouth twice a day and as needed, but there was no active order for hydroxyzine in the medical record. Upon observation, hydroxyzine 25 mg was found in the medication cart for the resident, while hydroxyurea was not present. Interviews with an LPN revealed that medication orders were supposed to be double-checked and verified against the medication card, and the DON confirmed that nurses were expected to verify the correct medication was entered into the medical record. The incorrect entry of the medication order resulted in incomplete and inaccurate documentation in the resident's medical record.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control
Penalty
Summary
A deficiency was identified when a resident with multiple wounds and a peripherally inserted central catheter (PICC) line did not have enhanced barrier precautions (EBP) implemented as required. Despite physician orders for wound care and PICC line monitoring, there was no EBP signage or supplies outside the resident's room. Interviews with staff, including a CNA, LPN, and the Director of Nursing, revealed a lack of awareness and implementation of EBP for residents with wounds and indwelling catheters, including PICC lines. Staff reported not using gowns during care and were unsure about the need for EBP in such cases. Additionally, during a meal service, a plate guard that had fallen to the floor was picked up and placed back on the resident's plate by a CNA, without being cleaned or replaced. The CNA was unaware that the plate guard had been on the floor, and the Administrator later confirmed that the expectation was for dropped items to be replaced with clean ones and not reused. These actions demonstrated a failure to maintain proper infection prevention and control practices for the resident.
Failure to Document Timely APS Notification for Abuse and Neglect Allegations
Penalty
Summary
A deficiency was identified when the facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than two hours after the allegation was made, to the administrator, State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, for one resident with a history of anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia, the facility's documentation of two separate incidents—an elopement and an allegation of sexual abuse—did not include a documented date that APS was notified. In the first incident, the local police found the resident wandering outside the facility and transported him to a hospital; the facility's form indicated APS was notified, but no date was recorded. In the second incident, the resident reported rectal pain and alleged rape to a nurse, but again, while the form stated APS was notified, no date was documented. The current administrator confirmed that there was no additional documentation available to verify the timing of APS notification for either event.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement risk and severe cognitive impairment was not adequately supervised, resulting in two separate elopement incidents. The resident, who had diagnoses including anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia, was assessed as high risk for wandering and elopement. Physician orders and care plans specified the use of a wander guard device, frequent monitoring, and supervision, especially during exit-seeking behaviors. Despite these interventions, the resident was able to leave the facility unsupervised on two occasions. On one occasion, the resident exited through a gate that was left slightly open by visitors who had attended a church service at the facility. The gate, which required a code to enter, was not properly secured after the visitors left. The resident was found by local police wandering on a street near the facility and was transported to a hospital for evaluation. Staff interviews and documentation revealed that the wander guard alarm system was in place, but staff did not check the entire courtyard when the alarm sounded, and the gate was not secured as required. In another incident, the resident was able to leave the facility through the side gate of the courtyard. At the time, the wander guard was attached to the resident's wheelchair rather than his person, as he had previously removed the device from his leg. Documentation indicated that the resident was exit-seeking, and staff were aware of his behaviors, but the supervision and monitoring in place were insufficient to prevent his elopement. These lapses in supervision and failure to secure exit points directly contributed to the resident's ability to leave the facility unsupervised.
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 193 citations issued within 25 miles in the last 12 months — including the 4 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 Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| City Creek Post Acute | 0.5 mi | ★★★★★ | 6 | 0 |
| William E Christofferson Salt Lake Veterans Home | 2.1 mi | ★★★★★ | 7 | 0 |
| Pine Creek Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 8 | 0 |
| St Joseph Villa | 2.2 mi | ★★★★★ | 0 | 0 |
| Midtown Manor | 2.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Maple Ridge Rehabilitation And Nursing.
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.