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 July 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.
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.
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.
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What surveyors actually found near you
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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.
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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) |
|---|---|---|---|---|
| Monument Healthcare Cottonwood Creek | 0 mi | ★★★★★ | 0 | 0 |
| 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 |
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