Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health Services during CMS and state inspections, most recent first.
A resident dependent on staff for transfers, with a history of stroke and respiratory conditions, was transferred by a CNA using a sit-to-stand lift without the required second staff member and without proper securing. The resident slipped from the lift and fell, sustaining a lump to the head. Staff interviews confirmed the transfer was not performed according to the care plan or Kardex instructions.
A resident with a history of atrial fibrillation and heart failure experienced severe respiratory distress in a facility. Miscommunication between an LPN and RN led to a misunderstanding of the resident's critical oxygen saturation level. The RN did not perform a comprehensive assessment, and the LPN called a private ambulance instead of 911, delaying emergency care. The resident was found unresponsive by EMS and passed away in the ambulance. The facility's failure to ensure effective communication and timely intervention resulted in Immediate Jeopardy.
A resident with severe cognitive impairment and multiple medical conditions was sent to a chemotherapy appointment covered in dried emesis, compromising their dignity. The van driver and Cancer Center staff reported the condition, but facility staff did not take action to clean or change the resident before departure. The facility's Medical Records staff denied receiving communication about the incident, and no immediate response was provided by the facility.
The facility failed to maintain a clean and homelike environment, as two residents' wheelchairs were found dirty and in disrepair. Despite procedures for cleaning on the night shift and as needed, the wheelchairs remained uncleaned, with one having exposed foam on the armrests. The DON confirmed the cleaning protocol, but observations showed it was not followed.
The facility failed to thoroughly investigate an alleged abuse incident involving two residents. The investigation did not include interviews with the LPN who witnessed the incident or other residents who might have had knowledge of the behavior. Only the two residents involved were interviewed, both of whom denied any inappropriate behavior.
The facility failed to assess two residents for competency and ability to consent to a sexual relationship, despite staff observations of their close interactions and an incident where one resident was found fondling the other. Both residents had moderate cognitive impairments, and the necessary assessments were not conducted.
The facility failed to comprehensively assess and care plan for two residents with histories of trauma, leading to deficiencies in trauma-informed care. One resident's history of physical abuse was not identified during the initial assessment, and another resident's history of physical and sexual abuse was not fully documented until months after admission. Both residents exhibited clear emotional distress when triggered, yet the facility did not take timely action to address their needs.
Failure to Follow Resident Transfer Protocols Resulting in Fall
Penalty
Summary
The facility failed to ensure that staff followed the resident's individualized plan of care for safe transfers, resulting in an accident. A resident with a history of stroke, emphysema, COPD, and asthma, who was dependent on staff for all transfers, was care planned to be transferred with the assistance of two staff members using a gait belt and pivot technique. However, the resident's Kardex indicated a transfer with one staff member using a gait belt and walker. On the day of the incident, a CNA attempted to transfer the resident using a sit-to-stand mechanical lift without the required assistance of a second staff member and without properly securing the resident in the lift. During the transfer, the resident slipped out of the sling and fell to the floor, sustaining a lump to the back of the head. Interviews with facility staff confirmed that the CNA acted alone and did not follow the care plan or Kardex instructions. The DON stated that the CNA had not previously used the lift for this resident and could not determine why the CNA chose this method. The LPN who responded to the incident found the resident on the floor and confirmed that the resident was not strapped into the lift at the time of the fall. The resident was sent to the hospital for evaluation and returned with no internal injuries, as confirmed by MRI.
Failure to Provide Timely Emergency Care Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that residents received treatment and care consistent with the Wisconsin Nurse Practice Act, resulting in a finding of Immediate Jeopardy. This deficiency involved two residents, with a particular focus on one resident who experienced a significant change in condition. The resident, who had a history of atrial fibrillation, heart failure, and other medical conditions, was admitted to the facility following a hospital stay. During the night, the resident exhibited symptoms of respiratory distress, including shortness of breath, increased pulse and respirations, and a critically low oxygen saturation level of 65%. The Licensed Practical Nurse (LPN) on duty sought assistance from a Registered Nurse (RN) for a second opinion. However, there was a miscommunication between the LPN and RN regarding the resident's oxygen saturation level, with the RN mistakenly believing it was 85% instead of 65%. The RN listened to the resident's lung sounds but did not perform a comprehensive assessment. Despite the resident's critical condition, the LPN obtained an order to transfer the resident to the hospital and called a private ambulance service instead of 911, leading to a delay in emergency medical care. Upon the arrival of Emergency Medical Services (EMS), the resident was found to be in severe respiratory distress and unresponsive, ultimately passing away in the ambulance while still at the facility. The facility's failure to ensure effective communication between nursing staff, complete a comprehensive assessment of the resident's condition, and promptly recognize and respond to the acute change in condition contributed to the deficiency. The delay in providing emergency medical care by not calling 911 when the resident's oxygen saturation was critically low was a significant factor in the finding of Immediate Jeopardy. This incident highlights the importance of accurate communication, thorough assessment, and timely intervention in managing residents' health conditions in long-term care settings.
Removal Plan
- Director of Nursing completed an audit of residents requiring transfer from facility to higher level of care to verify appropriate provider notification and Emergency Medical Services activation.
- Facility Licensed Nursing staff reeducated by Director of Nursing or designee on Change of Condition of the Resident policy. This re-education included information on assessing or data gathering and reporting findings requiring immediate notification to the medical provider. Re-education includes use of the INTERACT 4.5 Change in Condition Guidelines for when to immediately notify the physician/provider. Reeducation also includes when to activate Emergency medical services by calling 911 for residents requiring emergency intervention.
- Director of Nursing or Designee will review facility charting daily to identify resident change in condition, to ensure proper documentation of change of condition and notification of provider including method of transfer and if 911 contacted or ambulance service contacted. These audits will be completed daily, then with morning clinical 5 days per week or until substantial compliance is maintained. Results of these audits will be brought to QAPI for review and recommendation.
Resident Sent to Chemotherapy Appointment in Undignified Condition
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, was treated with dignity and respect during transportation to a chemotherapy appointment. R2, who has severe cognitive impairment and multiple medical conditions including cerebral palsy and colon cancer, was sent to the appointment covered in dried emesis. The van driver and staff at the Cancer Center reported that R2 arrived in this condition, and the van driver noted that the facility staff did not take action to clean or change R2 before departure. Additionally, there were reports from the Cancer Center staff that R2 had previously arrived wet from urine and with a mask filled with food. The incident was reported to the facility's Medical Records staff, who denied receiving any such communication. The Director of Social Services confirmed the duration of R2's chemotherapy appointments, but no further information was provided by the facility regarding the incident. The Director of Nursing was informed of the concern, but the report does not indicate any immediate response or acknowledgment of the deficiency by the facility at the time of the surveyor's inquiry.
Deficiency in Wheelchair Maintenance and Cleanliness
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for residents, as evidenced by the condition of two wheelchairs observed during the survey. One resident's wheelchair was found to be dirty, with dried food on the center and under the seat, dirty and dusty wheels, and brakes covered with dried food crumbs. Additionally, the armrests were in poor condition, with the foam exposed due to missing leather coverings. Despite the facility's procedure for cleaning wheelchairs on the night shift and as needed on shower days, the resident's wheelchair remained uncleaned and unrepaired, indicating a lapse in the facility's maintenance and cleaning protocols. Another resident's wheelchair was also observed to be dirty, with multiple small food crumbs and debris under the cushion and dried food on the seat. The Director of Nursing confirmed that wheelchairs are expected to be cleaned on the third shift and as needed, but the observations indicated that this procedure was not followed. The failure to maintain clean and well-maintained wheelchairs suggests a deficiency in the facility's ability to provide a safe and homelike environment for its residents.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility did not thoroughly investigate an alleged abuse incident involving two residents. A Licensed Practical Nurse (LPN) found one resident fondling another resident's breasts in the latter's room. Although an investigation was initiated and a Facility Reported Incident (FRI) was submitted to the State Agency, the management failed to interview the LPN who witnessed the incident. Additionally, no other residents were interviewed to determine if they had any concerns or had witnessed any inappropriate behavior between the two residents involved in the incident. The facility's Abuse, Neglect, and Exploitation policy requires a thorough investigation, including identifying and interviewing all involved persons, such as the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. However, the investigation summary lacked interviews with other residents and the LPN who discovered the incident. The only interviews conducted were with the two residents involved, both of whom denied any inappropriate behavior and expressed that they felt safe and comfortable in the facility. The surveyor's review of the investigation revealed inconsistencies in the statements from the facility's staff. The Assistant Executive Director and Social Services Director claimed that the LPN was interviewed, but the Nursing Home Administrator later confirmed that the LPN was not interviewed. This discrepancy, along with the lack of interviews with other residents, indicates that the facility did not follow its own investigation procedures, leading to an incomplete investigation of the alleged abuse incident.
Failure to Assess Residents' Ability to Consent to Sexual Relationship
Penalty
Summary
The facility failed to comprehensively assess two residents (R1 and R2) for competency, ability to consent to a sexual relationship, or intimacy and sexual history assessment. Both residents were found in a compromising situation where R2 was fondling R1's breasts. Prior to this incident, staff had observed the residents spending significant time together and holding hands, but no assessments were conducted to evaluate their understanding and consent to such interactions. R1 was admitted with diagnoses including Cerebral Atherosclerosis, Cognitive Communication Deficit, and Anxiety, and had a BIMS score indicating moderate cognitive impairment. Similarly, R2 was admitted with diagnoses including Orthostatic Hypotension, Dementia, and Alcohol Induced Amnestic Disorder, also with a BIMS score indicating moderate cognitive impairment. Despite these cognitive impairments, the facility did not conduct the necessary assessments to determine their ability to consent to a sexual relationship. The investigation revealed that the facility's Social Services Director and Coordinator did not use the provided guidelines to assess the residents' ability to consent. They only asked two questions about the residents' understanding of their rights to have a relationship and to say no, rather than using the four specific questions recommended for assessing competency. Additionally, the refusal of the residents to answer the questions was not documented, and no assessments were completed prior to the incident, despite staff observations of the residents' close interactions.
Deficiency in Trauma-Informed Care for Residents
Penalty
Summary
The facility failed to comprehensively assess and care plan for two residents with histories of trauma, leading to deficiencies in trauma-informed care. Resident R1 was admitted with a history of physical abuse that was not identified during the initial psychosocial assessment. It was only after a facility-wide Trauma Informed Care Assessment on 5/1/24 that R1's history of physical abuse was recognized. Despite this, no care plan or approaches to mitigate triggers and prevent re-traumatization were put in place for R1 after the assessment was completed. This oversight was confirmed during an interview with the Social Services Director, who was unable to explain why the initial assessment failed to identify the trauma and why the subsequent care plan was not implemented. Similarly, Resident R3 was admitted with a history of physical abuse that was identified during the initial psychosocial assessment. However, this information was not transferred to R3's care plan. It was only after the facility's Trauma Informed Care Assessment on 5/1/24 that R3's history of both physical and sexual abuse was fully documented. Prior to this, R3 had no care plan approaches to mitigate any triggers to prevent re-traumatization. The Social Services Director and Nursing Home Administrator both acknowledged the delay in identifying and addressing R3's trauma, attributing it to a lack of communication and the recent involvement of R3's sister/POA. The facility's failure to implement trauma-informed care plans for these residents was further highlighted by the fact that both residents had documented triggers and reactions to their past traumas. R1 often became sad and tearful when reminded of her past abuse, while R3 exhibited severe emotional distress, including crying and screaming, when triggered. Despite these clear indicators, the facility did not take timely action to address their needs, resulting in a significant deficiency in providing trauma-informed care.
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What surveyors actually found near you
We read the 852 citations issued within 25 miles in the last 12 months — including the 24 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Milwaukee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Greenfield | 0.1 mi | ★★★★★ | 5 | 1 |
| Complete Care At Southpointe | 1.8 mi | ★★★★★ | 19 | 0 |
| Greendale Park Nursing And Rehab | 1.8 mi | ★★★★★ | 42 | 0 |
| Sunrise Health Services | 3.1 mi | ★★★★★ | 1 | 0 |
| Medical Suites At Oak Creek (the) | 3.2 mi | ★★★★★ | 54 | 3 |
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