Maple Ridge Rehabilitation and Nursing

Inspectors wroteBased on interview and record review, the facility failed to protect each resident's right to be free from neglect for 1 of 19 residents. Specifically, facility staff failed to provide the necessary care and supervision required to maintain a safe environment for a resident with known impulsivity and severe cognitive impairment. This failure occurred when a Registered Nurse (RN) left a medication cart unlocked and unattended, in direct violation of facility policy and the resident's specific care plan interventions dated 9/17/25. This breach in safety protocols allowed the resident to access the unsecured cart and ingest multiple medications not prescribed to him. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to store all medications in a locked compartment and limit access only to authorized staff. Specifically, for 1 of 19 sampled residents, a resident was able to access the medication cart that was unlocked and unattended in a public hallway, allowing the resident to obtain multiple medications blister packs, and possibly ingest of unauthorized medication. This resulted in a finding of harm. Resident Identifier: 32. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder. Review of resident 32's medical record was completed on 6/1/26 through 6/4/26. On 3/13/25 at 12:10 PM, an Event Note Template revealed the following: Event Date/Time: [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that the transfer and discharge process was properly documented and that the required notifications were sent to the Office of the State Long-Term Care Ombudsman. Specifically, for 3 of 19 residents who were reviewed, the facility failed to maintain evidence that a copy of the written transfer notice was sent to the Ombudsman at the time of the transfer. Resident Identifiers: 2, 20, and 40.1. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure with hypoxia, schizophrenia, and acquired absence of lung. A review of resident 20's progress notes revealed the following hospital transfers:4/24/26 at 5:13 AM, a health status note documented, Resident was c/o [complaining of] 10/10 burning stomach pain. He started vomiting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an allegation of resident neglect was reported to the State Survey Agency and other required officials within the mandatory federal timeframe. Specifically, after a medication cart was left unlocked and unattended, and a resident ingested multiple medications from the unlocked medication card, the facility failed to report this allegation of neglect and misappropriation to the State Survey Agency within 2 hours of discovery. Resident Identifier: 32Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder. Review of resident 32's medical record was completed on 6/1/26 through 6/4/26. On 3/13/25 at 12:10 PM, an Event Note Template revealed the following: Event Date/Time: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, 4 out of 19 residents, resident 32 obtained medications independently from an unsecured, unlocked medication cart. This will be cited at a harm level. In addition, the facility failed to implement new or revised interventions after consecutive falls. Resident 40 will also be cited at a harm level. Resident Identifiers: 2, 26, 32, and 40. HARM1. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder. Review of resident 32's medical record was completed on 6/1/26 through 6/4/26. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that the pharmacist's monthly drug regimen review recommendations were documented and acted upon. Specifically, for 1 out of 19 residents reviewed the facility failed to ensure that the pharmacist's March 2026 recommendation to update order from as needed to a scheduled medication was addressed. This resulted in a three-month delay until June 2026 without any medication update. Resident Identifier: 13. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included radiculopathy, lumbosacral region and major depressive disorder. Review of resident 13's medical record was completed on 6/1/26 through 6/4/26. [...]

Inspectors wroteBased on interview and record review it was determined the facility did not provide or obtain laboratory services to meet the needs of the residents. Specifically for 2 out of 19 sampled residents a resident did not have his Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipid Panel and a Valproic Acid level drawn every 6 months and another resident did not have their monthly CBC lab drawn. Resident Identifiers: 12 and 27.1. Resident 12 was admitted [DATE], readmitted [DATE] with diagnoses including, but not limited to schizophrenia, chronic diastolic (congestive) heart failure, and unspecified intracranial injury. Resident 12's medical record was reviewed from 6/1/26 through 6/4/26. A physician's order dated 9/29/25 stated, Draw CBC [complete blood count] monthly r/t [related to] clozaril use. This order was discontinued 3/6/26. [...]

Inspectors wroteBased on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically for 2 out of 19 sampled residents, a resident had a complete blood count (CBC), comprehensive metabolic panel (CMP), valproic acid level, and lipid level collected without a physician's order. Additionally, a resident had a glycated hemoglobin (HgbA1C), CMP, CBC with differential, prolactin, valproic acid, and lipid panel collected without a physician's order. Resident identifiers: 19 and 27.1. Resident 27 was admitted to the facility on [DATE] with diagnoses which included, cerebral infarction, generalized anxiety disorder, adjustment disorder with depressed mood, and insomnia. On 5/28/26 at 5:32 PM, a health status note documented, Late Entry: [...]

Inspectors wroteBased on interview and record review, it was determined for 1 of 19 sampled residents, that the facility did not ensure that laboratory results were filed in the resident's clinical record. Specifically, the facility did not include 6 monthly physician ordered complete blood counts in a resident's medical record. Resident Identifier: 12Resident 12 was admitted [DATE], readmitted [DATE] with diagnoses including, but not limited to schizophrenia, chronic diastolic (congestive) heart failure, and unspecified intracranial injury. Resident 12's medical record was reviewed from 6/1/26 through 6/4/26. A physician's order dated 9/29/25 stated, Draw CBC [completed blood count] monthly r/t [related to] clozaril use. This order was discontinued 3/6/26. A physician's order dated 3/6/26, stated, Draw CBC monthly r/t clozaril use. [...]

Inspectors wroteBased on interview and record review, the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, for 2 out of 19 sampled residents a resident had an incorrect medical diagnosis and another resident had an incorrect diagnosis for a medication given. Resident identifiers: 6 and 27.1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease, adult failure to thrive, mild cognitive impairment, and major depressive disorder. A review of resident 6's Minimum Data Set, dated [DATE] documented that resident 6 had a diagnosis of Schizophrenia. A review of resident 6's medical record revealed that resident 6 did not have a Preadmission Screening and Resident Review (PASRR) level 2 with a diagnosis of Schizophrenia. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not 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. Specifically, for 2 of 19 sampled residents, Enhanced Barrier Precautions [EBP] were not being implemented as ordered. Resident identifiers: 2 and 27.1. Resident 2 was admitted on [DATE] with diagnoses which included, non-pressure chronic ulcer of foot, sepsis, and acquired absence of right foot. On 6/1/26 at 9:02 AM, an observation and interview were conducted with resident 2. There was no observed EBP signage or Personal Protective Equipment (PPE) available for use in the resident's room. Resident 2 was observed to have her right foot wrapped in a bandage. [...]

Inspectors wroteBased on interview, the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. Specifically, the facility did not employ a full-time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of nutrition services.

Inspectors wrote4. Resident 26 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, hemiplegia and hemiparesis of left side, dysphagia, aphasia, and hypertension. Resident 26's medical record was reviewed. On 12/26/24, resident 26 had a physician order initiated for a laboratory draw for a Prothrombin Time (PT) and International Normalized Ratio (INR). The laboratory results were not located in resident 26's medical record. On 5/29/25, the facility emailed a copy of the PT/INR laboratory results for the 12/26/24, order. On 5/29/25 at 2:47 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the 12/26/24, INR was printed from the laboratory website and was not located in resident 26's medical record. On 6/2/25 at 7:40 AM, a follow-up interview was conducted with the ADM. [...]

Inspectors wroteBased on interview and record review, the facility did not allow the resident the right to formulate an advance directive. Specifically, for 1 out of 14 sampled residents, a resident that did not have a Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive was documented as full code in their medical record. Resident identifier: 32.

Inspectors wroteBased on interview and record review, it was determined, for 1 out of 14 sampled residents, the facility did not make prompt efforts to resolve grievances the resident may have or maintain evidence demonstrating the results of all grievances. Specifically, a resident reported that his wallet and all personal documents were missing and requested assistance with obtaining new identification (ID) cards and the facility did not maintain evidence demonstrating the grievance investigation and decision. Resident identifier: 18.

Inspectors wroteBased on interview and record review, it was determined, for 1 of 14 sampled residents, the facility did not ensure that residents who use psychotropic drugs received a gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, a resident did not have an attempted GDR for Depakote and the Trazodone did not have a rationale for the clinical contraindication. Resident identifier: 26.

Inspectors wroteBased on interview and record review, it was determined, for 1 of 14 sampled residents, the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made to the administrator, the State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, the facility investigations for a residents allegation of sexual abuse and an elopement did not have a documented date that APS was notified. Resident identifier: 1.

Inspectors wroteBased on interview and record review, it was determined, for 2 of 14 resident's sampled, the facility did not ensure that the resident's transfer or discharge was documented in the resident's medical record and the information was communicated to the receiving provider included contact information for the practitioner responsible for the care of the resident; resident representative contact information; Advanced Directive information; all special instructions or precautions for ongoing care; a comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, the resident's medical record did not contain documentation of what information was sent to the receiving provider for a transition of care. Resident identifiers: 7 and 15. 1. [...]

Inspectors wroteBased on interview and record review, it was determined, for 1 of 14 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet the resident's medical, nursing, and psychosocial needs that were identified in the comprehensive assessment. Specifically, the resident's care plan did not address the resident's bowel elimination pattern. Resident identifier: 4.

Inspectors wroteBased on interview and record review, it was determined, for 1 of 14 sampled residents, the facility did not ensure that all residents received the treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, a resident had complaints of constipation that were not treated with the facility bowel protocol. Resident identifier: 4.

Inspectors wroteBased on observation, interview, and record review, it was determined, for 1 of 14 sampled residents, the facility did not ensure that the resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident elopement from the facility on two occasions. Resident identifier: 1.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 14 sampled residents, a resident complaining of pain and requesting to go to the hospital was not provided pain medications, an alternative pain reliever, or nonpharmaceutical pain interventions. Resident identifier: 14.

Inspectors wroteBased on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the expiration date when applicable. Specifically, for 1 out of 14 sampled residents, an opened multi use vial of Humalog had expired and a multi use vial of aplisol was not labeled with an open or a discard date. Resident identifier:

Inspectors wroteBased on interview and record review, it was determined, for 1 of 14 sampled residents, the facility did not maintain medical records on each resident that was complete and accurately documented. Specifically, a resident's medication order was entered incorrectly in the medical record. Resident identifier: 15.

Inspectors wroteBased on observation, interview, and record review, it was determined, for 1 out of 14 sampled residents, the facility did not 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 disease and infections. Specifically, a resident with a peripherally inserted central catheter (PICC) line and open wounds did not have enhanced barrier precautions (EBP) initiated and a plate guard that dropped to the floor was used on the resident's lunch plate. Resident identifier:

Inspectors wroteBased on interview and record review, for 4 of 6 sampled residents, the facility failed to provide the residents the right to participate in the development and implementation of a person-centered care plan, the right to attend meetings regarding the person-centered plan of care, the right to attend meetings regarding the person-centered plan of care, and the right to request revisions to the person-centered plan of care. Specifically, resident's representatives were not informed or included in care planning meetings in which concerns regarding the resident's plan of care could be discussed. Resident identifiers: 1, 2, 4 and 6.

Inspectors wroteBased on interview and record review it was determined, for 2 of 6 sampled resident, the facility did not ensure residents were free of any significant medication errors. Specifically, a resident was administered another residents medications. In addition, there was no documented monitoring after the medications were administered. Resident Identifiers: 3 and 6.

Inspectors wroteBased on observation, interview, and record the review, it was determined, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 18 sampled residents, a resident that was observed and verbally expressed their pain was not provided pain medication. In addition, there was a delay in the facility Medical Doctor (MD) responding to the nurses message regarding resident 33's pain. Resident identifier: 33.

Inspectors wroteBased on observation, interview and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 18 sampled residents, a resident that required a cigarette smoking extender was not provided one during observed smoking sessions. In addition, chemicals on the cleaning cart were unlocked and stored in the resident television (TV) room. Resident identifier: 25.