Maple Ridge Health Services

Inspectors wroteBased on observation, interviews and policy review, the facility failed to ensure kitchen staff covered exposed hair with a hair net while plating food to serve to residents for one of one kitchen with the potential to affect 70 out of 73 census residents consuming food out of the kitchen. This failure had the potential to cause unsanitary food to be served to residents.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to follow their grievance process and file a grievance after a concern was brought to the attention of staff for one of three residents (Resident (R) 5) reviewed for grievances of 15 sample residents. This had the potential to affect all residents in the facility who had concerns.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident's weights were obtained according to the physician's orders for one of three residents (Resident (R) 1) reviewed for quality of care of 15 sample residents. This failure had the potential for R1 to have an unassessed change in weight which could cause a decline in condition.

Inspectors wroteBased on record review and interviews, the facility failed to ensure physician ordered medication was provided for two of five residents (Resident (R) 6 and R3) reviewed for medication administration of 15 sample residents. This failure had the potential to cause medical complications and a decline in condition.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure personal protective equipment for enhanced barrier precautions were in place during high contact care for two of three residents (Resident (R) 6 and R14) reviewed for enhanced barrier precautions (EBP's) of 15 sample residents These failures had the potential to cause the spread of infection.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure two staff members transferred a resident which resulted in an injury for one of 11 residents (Resident (R) 1) reviewed for accidents. This had the potential to cause injuries during improper transfers.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R20) of 18 residents reviewed had a comprehensive care plan developed and implemented so that residents can attain their highest practicable physical, mental and psychosocial well-being. * R20 started receiving dialysis on December 7, 2024. R20's comprehensive care plan does not address the need for dialysis and the care and treatment of R20's dialysis site.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that 2 (R43 & R33) of 5 residents reviewed received care, consistent with professional standards of practice, to prevent pressure injuries and ensure that residents do not develop pressure injuries. *R43 is at risk for the development of pressure injuries and was observed to have their heels resting against a surface and not offloaded to prevent pressure injury development. * R33 is at risk for the development of pressure injuries and was observed to have their heels resting against a surface and not offloaded to prevent pressure injury development.

Inspectors wroteBased on interview and record review, the facility did not ensure residents received treatment and care consistent with N6 Wisconsin Nurse Practice Act for 2 (R3 & R1) of 4 residents reviewed. R3 was admitted to the facility on [DATE]. During the night of [DATE], R3 experienced a change of condition including having shortness of breath, increased pulse and respirations, and oxygen (O2) saturations of 65% (as obtained by Licensed Practical Nurse (LPN)-N. LPN-N sought out Registered Nurse (RN)-L for a second opinion. LPN-N and RN-L had a miscommunication as RN-L believed R3's O2 sats were 85%. RN-L listened to R3's lung sounds but did not complete a comprehensive assessment of R3's change of condition. LPN-N obtained an order to transfer R3 to the hospital and called a private ambulance service. Upon EMS arrival, they found R3 to be in severe respiratory distress and unresponsive. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure 1 Resident (R2) of 3 sampled Residents were treated with dignity and respect. *The facility sent R2 to a chemotherapy appointment covered in emesis. Findings Include: R2 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy, Malignant Neoplasm of Colon, Chronic Obstructive Pulmonary Disease, Legal Blindness, and Essential Hypertension. R2 has an activated Health Care Power of Attorney (HCPOA). R2's Quarterly Minimum Data Set (MDS) completed 9/12/24 documents R2's Brief Interview for Mental Status (BIMS) score to be 4, indicating R2 demonstrates severely impaired skills for daily decision making. R2 is documented as having no mood or behavior issues. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure a clean, comfortable, and homelike environment which had the potential to affect 2 (R1 and R2) of 3 wheelchairs observed during the survey process. *R1's wheelchair was observed to be dirty during the survey. *R2's wheelchair was observed to be dirty, and the arm rests in need of repair during the survey. Findings Include: R2 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy, Malignant Neoplasm of Colon, Chronic Obstructive Pulmonary Disease, Legal Blindness, and Essential Hypertension. R2 has an activated Health Care Power of Attorney (HCPOA). R2's Quarterly Minimum Data Set (MDS) completed 9/12/24 documents R2's Brief Interview for Mental Status (BIMS) score to be 4, indicating R2 demonstrates severely impaired skills for daily decision making. R2 is documented as having no mood or behavior issues. [...]

Inspectors wroteBased on interview and record review, the facility did not thoroughly investigate 1 of 2 Facility Reported Incidents (FRI) reviewed for alleged abuse. R1 and R2 were found in R1's room and R2 was fondling R1's breasts. An investigation was opened and FRI submitted to the State Agency. The staff member who found the residents, Licensed Practical Nurse (LPN)-F, was not interviewed by the management preparing the investigation. No residents were interviewed to rule out the extent of R2's behavior or if others witnessed or had knowledge of potential inappropriate contact between R1 and R2.

Inspectors wroteBased on interview and record review, the facility did not comprehensively assess 2 (R1 and R2) of 4 residents reviewed for alleged abuse. The facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, to have the highest practicable physical, mental, and psychosocial well-being. R1 and R2 were found in R1's room and R2 was fondling R1's breasts. Prior to this incident, R1 and R2 were spending lots of time together including being found holding hands. The residents were not assessed for competency, ability to consent to a sexual relationship or intimacy and sexual history assessment completed.

Inspectors wroteBased on record review and interview, the facility did not comprehensively assess 2 (R1 and R3) of 3 residents reviewed for trauma informed care and care plan approaches to mitigate any triggers to prevent re-traumatization. ~ R1 was admitted [DATE] and during her admission psychosocial assessment, the facility did not identify R1 as having a history of physical abuse. On 5/1/24 the facility completed Trauma Informed Care Assessments for all high risk residents. R1's past history of physical abuse was then identified. A care plan and approaches to mitigate any triggers to prevent re-traumatization was not put in place after the assessment for R1 had been completed. ~ R3 was admitted on [DATE] and during her admission psychosocial assessment, the facility identified R3 as having a history of physical abuse. This information was not transferred to R3's plan of care. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure food was prepared safely, for 75 of 75 Residents who eat food prepared in the main kitchen. On 1/23/24, the 2 thermometer probes were not sanitized between taking the temperatures of different food items.

Inspectors wroteBased on record review and interview, the facility did not review and revise Comprehensive Care Plans by the interdisciplinary team with resident voice after comprehensive and quarterly assessments for 7 (R13, R7, R14, R47, R22, R24 and R15) of 18 sampled residents. R13, R7, R14, R47, R22, R24, and R15 did not have quarterly care conferences with the Interdisciplinary Team (IDT) and resident or resident representative and did not have documentation of inviting the resident or resident representative and their declination of the invitation.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R54) of 2 residents reviewed for psychotropic medication were being assessed and monitored appropriately to be free from unnecessary drugs. R54 started Quetiapine/Seroquel (Antipsychotic) and did not have an AIMS (Abnormal involuntary movement scale) completed at the start of the medication. When the AIMS was completed, there was a recommendation for a neurological exam based off of the score indicated. There was no follow up on this recommendation or reassessment of the AIMs score.

Inspectors wroteBased on observation, interview and record review the facility did not ensure its medication error rates are not 5 percent or greater. There were 2 errors in 29 opportunities for an error rate of 6.9% for R3 and R22. * R3 was administered Senna Plus (Docusate Sodium/Sennosides) versus regular Senna as ordered by the Physician. * R22's Medication Administration Record (MAR) documented an order for Atropine 0.01% versus 1% as ordered by the Physician.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 2 of 3 medication carts reviewed in the facility. * Medication carts contained insulin that was not labeled, dated and/or expired. On [DATE] Surveyor observed a Levemir insulin pen which was open and used, but not dated when opened. In addition, there was no label or name on the insulin pen. On [DATE] Surveyor observed R23's Levemir insulin vial was open and used dated wither 6/13 or [DATE]. Once opened this product expires 42 days after first use or removal from the refrigerator which ever comes first. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety as required for 72 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents.

Inspectors wrote2.) R13 was admitted to the facility on [DATE]. R13's admission MDS (Minimum Data Set) dated 6/17/22 indicates that they require total assistance with activities of daily living including bed mobility. R13 is rarely to never understood. R13 was noted to be at high risk for pressure injuries. On 9/14/22 at 3:50 PM Surveyor observed R13's feet resting directly on their mattress. On 9/14/22 at 9:50 AM, Surveyor observed R13's feet resting directly on their mattress. On 9/14/22 at 12:35 PM, Surveyor observed R13's feet resting directly on their mattress. On 9/14/22 at 3:00 PM, Surveyor observed R13's feet resting directly on their mattress. On 9/15/22 at 8:35 AM, Surveyor observed R13's feet resting directly on their mattress. On 9/15/22 at 10:40 AM, Surveyor observed R13's feet resting directly on their mattress. [...]

Inspectors wroteBased on food complaints from R38, R35, R33, R24, & R20, during the Resident Council meeting with Surveyors, 8 of 11 Residents raised their hands to indicate the food is not hot, and testing lunch food items on 9/19/22, the Facility did not ensure Resident's food was palatable for 13 of 72 residents who receive their meals from the kitchen.

Inspectors wroteBased on observation, interview and record review the Facility did not treat 1 (R18) of 3 Residents reviewed with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the environment was safe, clean, comfortable, and homelike for 1 (R19) of 19 sampled residents. R19's room had medications and debris in the air conditioning unit below the window that had been present for an indeterminate amount of time.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R73) of 1 resident reviewed was properly assessed for physical restraints. R73 did not have an assessment for an abdominal binder that was to be on at all times.

Inspectors wroteBased on interview, and record review the facility did not ensure a comprehensive care plan was reviewed and revised to incorporate all aspects of the resident's medical status for 1 (R21) of 19 sampled residents. R21 was taking an anticoagulant medication and the comprehensive care plan did not include the effects of the medication or the interventions to ensure R21 did not have bleeding concerns from the medication.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice for non-pressure injuries for 2 (R19 and R18) of 19 sampled residents. *R19 was admitted on [DATE] with a wound to the left inner buttocks that was not comprehensively assessed until 9/18/2022, eighteen days after admission. The wound was categorized as a pressure injury with a treatment on admission, but the wound was not measured and the wound base was not described until 9/18/2022 where it was determined to be a non-pressure wound. *R18 had contractures to the hands and interventions of washcloths to the fists to prevent puncture wounds from the nails were observed to not be in place.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure proper foot care for 1 (R74) of 1 Residents reviewed for foot care. * R74's toenails were very long and in need of trimming.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 3 (R6, R13, R74) of 6 residents reviewed who are at risk for falls received the necessary services and supervision to prevent an injury from a fall or conduct through fall investigations. * The facility did not thoroughly investigate to determine a root cause analysis of R6's fall on 7/27/22. R6 sustained a hematoma to their face and were sent to the emergency room for evaluation. R6 is assessed to be at high risk for falls. R6's care plan and CNA (Certified Nursing Assistant) [NAME] indicates the use of a low bed and floor mat. On 9/14/22 and 9/15/22, Surveyor observed R6 in bed with no floor mat in place. On 9/15/22 Surveyor observed R6 in bed with the bed in high position. * R13 was at risk for falls and was observed by Surveyor in a bed in a high position. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 1 (R325) residents reviewed for urinary incontinence received appropriate treatment and services to restore continence to the extent possible. * R325 was admitted into the facility with urinary incontinency. The facility did not initiate a 3 day voiding pattern diary as part of their assessment to assist in determining what type of toileting program R325 may benefit from and in order to restore continence to the extent possible. R325's Bladder/Incontinence Evaluation with an effective date of 9/17/22 indicated a treatment program of scheduled toileting/habit training, which is not reflected on R325's care plan. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents maintained acceptable parameters of nutritional status such as usual body weight for 2 (R50 and R53) of 5 residents reviewed for nutrition. * R50 had severe weight loss of 27.8 pounds, a 14.4% loss, in twelve days that was not identified by the facility or Registered Dietician, and no notification was made to the physician or Nurse Practitioner. * R53 had a weight loss of 10.3 pounds, a 6.7% loss, in one month, with no re-weight to establish the validity of the weight loss, and no notification was made to the physician or Nurse Practitioner.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, including risk for dehydration for 1 of 2 (R13) residents reviewed for enteral feeding. R13's continuous tube feeding was observed disconnected from R13's PEG (percutaneous endoscopic gastrostomy) tube and lying on the floor.

Inspectors wroteBased on interview and record review the Facility did not ensure a CPAP (continuous positive airway pressure) machine (which delivers a stream of oxygenated air to the person's airway) was ordered, care planned, and cleaned for 1 (R25) of 1 Residents reviewed with CPAP machines. There is no physician order for R25's CPAP, there is no evidence R25's CPAP is being cleaned and there is no care plan.

Inspectors wroteBased on record review and interview, the facility did not always follow through on obtaining physician ordered labs for 1 of 1 resident reviewed for lab services. On 1/13/22, R73's physician ordered weekly basic metabolic panel (BMP) labs. The facility did not consistently follow through on obtaining the BUN lab. Surveyor noted missing BMP labs for 1/13, 1/20, 1/27, 2/3, 2/10, 2/17, 3/10, 3/17, and 3/24/22