Maple Ridge Health Services

Penalties

• Oct 17, 2024 — Fine ($14,433)

Inspection findings

1. Jul 1, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jul 18, 2025 · CMS health inspection

2. Apr 30, 2025 Fire Safety · 5 findings
   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected May 30, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected May 30, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected May 30, 2025 · CMS fire safety

3. Oct 17, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0557 Resident Rights Deficiencies

     Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

     Corrected Nov 18, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Nov 18, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Nov 18, 2024 · CMS health inspection

4. May 7, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jun 3, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jun 3, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Jun 3, 2024 · CMS health inspection

5. Jan 25, 2024 Health · 8 findings
   • Not serious Scope/severity E

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Mar 6, 2024 · CMS fire safety

6. Dec 21, 2023 Health · 1 finding
   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jan 10, 2024 · CMS health inspection

7. Aug 28, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Sep 28, 2023 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 28, 2023 · CMS health inspection

8. Oct 3, 2022 Health · 23 findings
   • Not serious Scope/severity D

     F0557 Resident Rights Deficiencies

     Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Nov 1, 2022 · CMS health inspection

   • Serious Scope/severity J

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0687 Quality of Life and Care Deficiencies

     Provide appropriate foot care.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0770 Administration Deficiencies

     Provide timely, quality laboratory services/tests to meet the needs of residents.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Nov 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Nov 1, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0233 Egress Deficiencies

     Install resident room doors of proper design and width.

     Corrected Nov 1, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Nov 1, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Nov 1, 2022 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Nov 1, 2022 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Nov 1, 2022 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Nov 1, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Nov 1, 2022 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Nov 1, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• BAUMANN, TROY — corporate director, NOT APPLICABLE, since 06/29/2017
• HOEHN, JEFFREY — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• HOEHN, JEFFREY — corporate director, NOT APPLICABLE, since 06/29/2017
• MILLS, DAVID — 5% or greater indirect ownership interest, 20%, since 06/29/2017
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• NSHF OPERATIONS LLC — 5% or greater direct ownership interest, 100%, since 07/24/2017