Maple Ridge Rehabilitation & Healthcare Center

Inspectors wroteBased on a review of clinical records, the Resident Assessment Instrument (RAI) User's Manual and staff interviews, it was determined the facility failed to ensure the Minimum Data Set assessments (MDS) accurately reflected the clinical status of 3 of twenty residents reviewed (Residents 59, 45, and 66).

Inspectors wroteBased on a review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to consistently monitor residents' nutritional and hydration status to timely identify declines, implement individualized and less invasive interventions, and ensure clinical justification prior to initiating invasive interventions for three of twenty residents reviewed (Residents 59, 45, and 66). This deficiency is cited as past noncompliance.

Inspectors wroteBased on observations, resident and staff interviews, clinical record review, and review of facility policy, it was determined the facility failed to provide a comfortable and homelike environment by failing to maintain acceptable sound levels from the resident call bell system on one of three floors observed (Fourth Floor), which resulted in ongoing excessive noise that disrupted rest and comfort for three residents (Residents 6, 61, and 73).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident out of 20 residents reviewed (Resident 79).

Inspectors wroteBased on observations, a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure the environment remained free from potential accident hazards related to the unsafe storage and access of medications for one of three nursing units reviewed (Unit 4) and for one of 20 residents sampled (Resident 58).

Inspectors wroteBased on a review of controlled drug shift count records, facility policy, and staff interviews, it was determined the facility failed to implement procedures to promote accurate controlled medication records for one of two medication carts observed.

Inspectors wroteBased on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure timely physician notification of clinically significant abnormal laboratory results for one of 20 residents reviewed (Resident 87). This deficiency is cited as past non-compliance.

Inspectors wroteBased on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve resident complaints and grievances expressed during Resident Council meetings and written grievances, including those voiced by for two of ten residents reviewed. (Residents 1 and 2).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined the facility failed to ensure a resident was invited to participate in the care planning process for one of 19 residents reviewed (Resident 42).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 19 residents reviewed (Resident 18).

Inspectors wroteBased on a review of clinical records, facility policy, and staff interview, it was determined the facility failed to consistently implement planned interventions and provide necessary treatment and services to prevent the worsening of a pressure ulcer for one resident out of four residents sampled for pressure ulcer care (Resident CR1) resulting in the worsening of a Stage 2 pressure ulcer to an unstageable pressure injury, constituting actual harm.

Inspectors wroteBased on review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to complete a comprehensive nutritional assessment and monitor resident weights consistently and accurately to timely identify changes in nutritional status and implement appropriate interventions to address weight loss for two of three residents reviewed for nutritional status and weight loss (Residents CR1 and A1).

Inspectors wroteBased on review of clinical records, document review, and resident and staff interviews, it was determined that the facility failed to provide an environment free from accident hazards to prevent potential incidents for one resident (Resident A1) out of eight sampled residents.

Inspectors wroteBased on a review of resident council meeting minutes and resident and staff interviews, it was determined that the facility failed to ensure that the facility considered the views and recommendations raised during resident group meetings, including experiences expressed by five residents out of five during a resident group interview (Residents 18, 31, 36, 49, and 86), and failed to ensure that the facility acted upon grievances and concerns raised during resident group meetings for one resident out of the 21 sampled (Resident 22).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to implement a person-centered care plan to meet each resident's needs for four of 21 sampled residents (Residents 7, 8, 64, and 66). Findings including: Review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include heart failure (chronic condition in which the heart does not pump blood as well as it should), and the presence of a pacemaker (small battery-powered device that prevents the heart from beating too slowly, surgically placed under the skin near the collar bone). A review of the resident's current comprehensive care plan, conducted during the survey ending August 9, 2024, failed to include the presence of a pacemaker. [...]

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to ensure comprehensive care plans were developed and revised with participation of the resident and the resident's representative for three residents out of 21 sampled (Residents 15, 31, and 49).

Inspectors wroteBased on observation, review of clinical records, select facility policy, and resident and staff interviews it was determined that the facility failed to timely identify and assess a resident's weight loss, implement individualized nutritional support measures to maintain or improve nutritional parameters, and to timely consult with the physician and notify the resident of a significant weight loss for one resident (Resident 22) and failed to implement a planned nutrition intervention in response to weight loss for one resident (Resident 142) of seven sampled residents.

Inspectors wroteBased on a review of clinical records, facility provided documents, facility's planned cycle menu, and resident and staff interviews it was determined that the facility failed to ensure a pre-planned nutritionally adequate menu for one resident out of 21 residents sampled (Resident 22).

Inspectors wroteBased on a review of clinical records, select facility policy and investigative reports, and staff interviews, it was determined that the facility failed to ensure that one resident out of 18 sampled (Resident 39) was free from physical abuse, perpetrated by another resident (Resident CR4).

Inspectors wroteBased on a review of clinical records, the Resident Assessment Instrument, and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 21 sampled (Resident 142).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to properly dispose of garbage and refuse

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and homelike resident environment on two of the three floors of the facility (the second, third floor and forth floor) and failed to maintain resident care equipment in clean and sanitary manner. Findings Include: An observation July 18, 2024 at 9 A.M. revealed a black substance on the air vent above the second floor nurses station, and two adjacent ceiling tiles. Observation on May 20, 2023, at 11:50 a.m. revealed that the floor of the second-floor community television and dining area was sticky floor and the feeling of resistance when lifting feet off of the floor to walk throughout the area. Dried liquid stains and food crumbs were observed in the refrigerator in the room. [...]

Inspectors wroteBased on a review of clinical records, guidance issued by the Centers for Medicare and Medicaid Services and facility documentation, and staff interview, it was determined that the facility failed to develop and implement policies and procedures designed to protect residents from unacceptable practices of disenrolling residents from their Medicare health plans by ensuring all risks of disenrolling are explained, both verbally and in writing, and the residents are found to be competent to make informed decisions for seven of 13 reviewed the facility disenrolled from Medicare health plans (Resident CR1, 13, 50, 59, 61, 75, and 81).