Maple Ridge Health Services

In the surveyor’s words

From the most serious findings on record at Maple Ridge Health Services, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jun 18, 2021

  Based on observation, interview and record review, the facility did not ensure manufacturer instructions for cleaning and disinfecting glucometers were being followed potentially spreading infection for 4 (R9, R39, R24, and R8) of 4 residents that were sharing a glucometer. On 6/9/2021, Licensed Practical Nurse (LPN)-F was observed to obtain R24's blood sugar. LPN-F went to another medication cart and retrieved antiseptic wipes that were individually packaged and were intended to be used to clean a cut or a wound. LPN-F wiped off the glucometer and wrapped the glucometer in the antiseptic wipe. Surveyor noted germicidal and bleach wipes were available in the bottom drawer of the medication cart. Surveyor asked LPN-F if bleach wipes were used to clean the glucometers. […]

• Immediate jeopardy, isolatedF684Oct 17, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF686Oct 3, 2022

  Based on interview and record review, the facility did not ensure Residents (R) without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 2 (R18 & R13) of 8 Residents reviewed for pressure injuries. *An unavoidable skin integrity care plan was developed for R18 on 09/02/20, which was R18's admitted . On 07/13/21, R18 was identified with a Stage 3 coccyx pressure injury. On 07/15/21, the facility developed a pressure ulcer actual or at risk care plan. R18's coccyx pressure injury healed on 07/20/21. […]

• Actual harm, patternF686Jun 18, 2021

  Based on observation, record review, and interview, the facility did not thoroughly assess, document, and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 7 (R43, R35, R211, R212, R161, R45, and R58) of 8 residents reviewed for pressure injuries. *R43 had pressure injuries to the coccyx and left heel that developed and healed multiple times. When the wounds were present, comprehensive assessments were not completed timely. R43's coccyx pressure injury initially assessed on 3/30/2021 was determined to be moisture associated skin damage and was changed to a Stage 3 pressure injury on 4/6/2021. […]

• Actual harm, isolatedF689Aug 26, 2026

  Based on observation, interview, and record review, the facility did not ensure 3 (R20, R67, R37) of 6 residents reviewed for accidents had adequate supervision to prevent accidents. *R20 fell out of the wheelchair while staff was pushing the wheelchair and sustained multiple right knee fractures. *R67 was assessed to require two staff to assist with bed mobility tasks and sustained a fall out of bed when being assisted by one staff member. *R37 is a smoker and did not have evidence of smoking assessments. Findings include: The facility policy titled Fall Prevention and Management Guidelines with revised date 7/18/24 documents: . […]