Health inspection·July 28, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of four residents out of 18 sampled (Resident 43, 66, 51 and 83). Residents Affected - Some Findings include: A review of Resident 43's quarterly MDS assessment dated [DATE], revealed in Section H0100 Appliances that the resident had an indwelling catheter. Section H0300, Urinary Continence indicated that the resident was always continent (coded 0), instead of coded as not rated (coded 9) due to the resident's an indwelling bladder catheter, condom catheter, ostomy, or no urine output for the entire 7 days. A review of Resident 66's significant change MDS assessment dated [DATE], revealed Section K0300 that the resident did have a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. However, a review of the resident's clinical record revealed no indication of a weight loss in the last month or last 6 months. Resident 51's quarterly MDS assessment dated [DATE], revealed that section K0200. Height and Weight indicated that the resident was 64-inches and weighed 122-pounds. Section K0300. Weight Loss, loss of 5% or more in the last month or loss of 10% or more in last 6 months was coded no or unknown and section K0310. Weight Gain, gain of 5% or more in the last month or gain of 10% or more in last 6 months was coded yes not on a prescribed physician weight-gain regimen. Review of Resident 51's nutrition progress notes completed by the registered dietitian (RD) on February 24, 2023, at 10:02 AM, revealed that the resident was assessed and her weight was 121.6-pounds with a BMI 20.9. The RD noted that the resident's weight stable was stable for one-month, but the resident had a significant weight loss of 16.9% in six months. Interview with the facility's registered dietitian (RD) on July 28, 2023, at 9:45 AM, confirmed that Resident 51's quarterly MDS section K0310 was coded incorrectly and that section K0300 should have been coded to reflect the resident's significant weight loss of 16.9% in six months. A review of Resident 83's discharge MDS assessment dated [DATE], section A. Identification Information Section A2100. Discharge Status was coded 03. Acute Hospital. Review of the resident's closed clinical record revealed a physician Discharge summary dated Page 1 of 12 395345 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0641 Level of Harm - Minimal harm or potential for actual harm [DATE], revealed that the resident went home with family and hospice services were to continue in the home. Interview with the DON (Director of Nursing) on July 27, 2023, at 1:23 PM, confirmed that the above MDS assessments were inaccurate. Residents Affected - Some 395345 Page 2 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to review and revise the resident's comprehensive care plan in response to new and increased behaviors displayed by one resident out of 18 reviewed (Resident 61). Findings include: A review of the clinical record revealed that Resident 61 was admitted to the facility on [DATE], and had diagnoses, which included Alzheimer's disease with early onset; an uncommon form of dementia that affects people younger than age [AGE]. A review of the resident's comprehensive plan of care implementation date April 8, 2022, revealed that the facility identified the resident's behavioral symptoms of restlessness, irritability, and feeling down. Revisions to the care plan were noted on November 5, 2022, to identify that the resident had a new behavior of physical aggression. Resident 61's clinical record revealed progress note documentation that the resident was exhibiting new behavioral concerns beginning in January of 2023, including hallucinations, pacing, increased agitation, and wanting to take his wanderguard off. Nursing progress notes revealed that these new and worsening behavioral symptoms continued throughout the months of January 2023, February 2023 and March of 2023. Further review of the resident's care plan, conducted during the survey ending July 28, 2023, revealed no documented evidence of revisions to the resident's care plan to include interventions developed to address the resident's worsening and new behavioral symptoms. There was no documented evidence that the facility revised the resident's comprehensive care plan to reflect interventions planned for staff use in response to Resident 61's current behaviors. Interview with the Director of Nursing on July 27, 2023, at approximately 9:30 a.m. confirmed there was no documented evidence that the resident's care plan was revised to address the resident's new and worsening behavioral symptoms. 28 Pa. Code 211.12(d)(3)(5) Nursing services 395345 Page 3 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select facility policy, and staff and resident interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to monitor bowel activity and implement physician's ordered bowel protocol to relieve constipation for two residents (Resident 19 and 25) out of 18 sampled residents. Residents Affected - Some Findings include: Review of a facility policy entitled Bowel (Lower Gastrointestinal Tract) Disorder - Clinical Protocol that was last reviewed by the facility May 2023, indicated that the staff and physician will monitor the individual's response to interventions and overall progress, for example, overall degree of comfort distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc. According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). A review of Resident 19's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included aphasia [a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain], weakness, and pain, unspecified. A review of Resident 19's bowel tracking report revealed that from June 3, 2023, 11:00 PM-7:00 AM shift, through June 11, 2023, 7:00 AM- 3:00 PM shift (23 shifts), revealed a lack of documented evidence that the resident's bowel activity was consistently and accurately monitored as evidenced by multiple blanks on the report with nothing recorded. A physician order dated July 17, 2023, at 7:57 AM, was noted for Milk of Magnesia Suspension [(MOM) reduces stomach acid, and increases water in the intestines which may induce bowel movements] 400 MG/5 ML (Magnesium Hydroxide) give 30 ml by mouth every 24 hours as needed for constipation and was given. The bowel tracking report from June 18, 2023, 3:00 PM- 11:00 PM, through June 23, 2023, 3:00 PM-11:00 PM (15 shifts) was not consistently completed to accurately reflect the resident's bowel activity to ensure that the resident received intervention, MOM, as needed for lack of bowel activity and to promote regularity. Review of Resident 25's clinical record revealed that the resident was initially admitted to the facility on [DATE], with diagnoses to have included dysphagia (difficulty swallowing) and Down's syndrome [is an individual - intellectual and developmental problems may be mild, moderate, or severe]. A physician order dated May 3, 2023, at 1:36 PM, was noted for Milk of Magnesia Suspension 400 mg (Magnesium Hydroxide) give 30 ml by mouth as needed for constipation administer if no bowel movement (BM) by the third day or 9 shifts, document effectiveness. If MOM was ineffective, administer a 395345 Page 4 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0684 Level of Harm - Minimal harm or potential for actual harm Dulcolax Suppository (Bisacodyl) [stimulant laxatives made to relieve occasional constipation] insert 1 suppository rectally as needed for constipation for no bowel movement within 24 hours after administration of MOM. Along with an order dated May 3, 2023, at 1:36 PM, for a Fleet Enema 7-19 GM/118 ML (Sodium Phosphates) insert 1 applicatorful rectally as needed for Constipation For no bowel movement by the end of the following shift after administration of suppository. Notify MD if ineffective. Residents Affected - Some A review of Resident 25's bowel tracking report revealed dated June 1, 2023, 3 PM-11 PM shift, through June 5, 2023, 7 AM- 3 PM shift (12 shifts) revealed that staff failed to consistently record the resident's bowel activity, or lack of, as evidenced by multiple unrecorded entries. Further review of the resident's bowel tracking report revealed that from June 10, 2023, 11PM-7AM shift, through June 16, 2023, 7 AM-3 PM shift (seventeen shifts), inconsistent documentation or unrecorded (blanks) to represent bowel movements. A review of the resident's Medication Administration Record (MAR) dated June 2023 revealed that there was no documented evidence that the physician prescribed medications to relieve constipation were administered as needed for lack of bowel movements. During an interview with the Director of Nursing on July 27, 2023, at 2:00 PM, the DON confirmed that the facility failed to consistently record and monitor Residents 19 and 25's bowel activity or lack of bowel movements to ensure that the physician prescribed bowel protocols were timely provided. 28 Pa Code 211.10 (a)(c)(d) Resident care policies. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services. 28 Pa. Code 211.5 (f) Medical Records 395345 Page 5 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select facility policies and staff interviews, it was determined that the facility failed to timely identify and assess residents with significant weight loss and review and revise interventions planned to maintain acceptable nutrition status for two residents out of five samples residents with significant weight loss (Residents 51 and 25). Residents Affected - Some Findings include: A review of a facility policy entitled Weight Monitoring Policy dated May 2023, indicated that residents are weighed for the first 4-weeks after admission and/or if otherwise ordered and then monthly. Weight changes of greater than or equal to five pounds need to be re-weighed. Significant changes of 5% weight gain/loss in 30-days or 10% in 6 months will be reported to the physician and family and discussed in the interdisciplinary team meeting. The facility policy entitled Nutritional Assessment indicated that the dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutrition assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Once current conditions and risk factors for impaired nutritional status are assessed and analyzed, individualized care plans will be developed that address or minimize to the extent possible the resident's risk for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preference. Review of Resident 51's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of dementia, aphasia [a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain], and obsessive-compulsive disorder [(OCD) is a common, chronic, and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and/or behaviors (compulsions) that he or she feels the urge to repeat over and over]. Review of the resident's care plan for nutrition initiated January 27, 2021, identified that Resident was at risk for altered nutritional status related to a history of CHF, generalized edema, dementia, behaviors, need for a mechanically altered diet, and at risk for unavoidable weight loss based on diagnosis and comfort measures with a goal to slow down weight loss as able. Planned interventions to deter weight loss were to honor food preferences, weigh as ordered, and supplements as ordered. Review of the resident's weight record dated February 1, 2023, at 2:45 PM, revealed that the weight recorded was at 121.6-pounds. A nutrition note completed by the facility's registered dietitian (RD) dated February 14, 2023, at 10:59 AM, revealed a quarterly assessment noting the resident's current weight of 121.6-pounds, body mass index (BMI) was 20.9 within normal limits (WNL), low for age, and weight was stable for one-month after a significant weight loss of 16.9% in 6-months. The resident's intakes were noted as variable with health shake (high calorie oral supplement) provided with meals. No changes were made and the RD noted the plan to continue to monitor. 395345 Page 6 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A nutrition note completed by the RD dated February 24, 2023, at 10:02 AM, continued to note that the resident's intakes were variable and the plan to continue with health shake with meals, but no changes were made to the resident's regimen or the plan to continue to monitor. Review of Resident 51's weight record revealed that the resident's weight recorded on March 2, 2023, at 11:07 AM, was 109.6-pounds. There was no re-weight noted. The resident had a significant weight loss of 12-pounds or 12% in 30 day. On April 2, 2023, at 2:25 PM, the resident's recorded weight was 106-pounds. A nutrition note completed by the RD on April 3, 2023, at 9:41 AM, indicated that the resident had a significant weight loss in six months of 22% loss of body weight and now weighed 106-pounds. BMI at 18.2 (classified as underweight). The resident's diet order was currently a regular, puree, thin liquids. The entry noted that the resident had a variable intake and continued to receive health shake three times per day. Despite the resident's progressive weight loss no revisions to the resident's nutritional support regimen were made and the RD's plan was to continue to encourage intake as resident allows. There was no evidence that resident's attending physician and interested representative were notified of the resident's 12-pounds weight loss or 12% loss of body weight in 30 days. The RD failed to timely address and review and revise the resident's nutritional support regimen to impede progressive, significant weight loss. Interview with the facility's RD on July 27, 2023, at 11:35 AM, confirmed that Resident 51's significant weight loss of 12-pounds or 9.8% in 30 days on March 2, 2023, was not addressed that that resident's plan was not reviewed and revised to deter further weight loss the RD also confirmed that there was no documented evidence that the resident's attending physician and interested representative were timely notified of significant weight loss. Review of Resident 25's clinical record revealed that the resident was initially admitted to the facility on [DATE], with diagnoses of dysphagia (difficulty swallowing) and Down's syndrome [is an individual intellectual and developmental problems may be mild, moderate, or severe]. A review of the resident's initial nutrition admission assessment completed by the facility's registered dietitian (RD) on May 5, 2023, at 8:29 AM, revealed that the resident's weight was noted as 133.8-pounds. The resident was dependent on staff for assistance at meals. The resident also had experienced vomiting episodes caused by brain cancer and the RD noted that a weight loss was likely. The RD recommended to add Boost pudding with the resident's lunch. Review of the Resident 25's initial care plan dated May 5, 2023, identified that the resident was at nutrition risk due to body mass index [(BMI) is a person's weight in kilograms (or pounds) divided by the square of height in meters (or feet) used to classify degrees of obesity] overweight, diagnosis of Down's syndrome, need for mechanically altered diet with need for supplements, dependent with meals with a goal for the resident to maintain adequate nutritional status. Planned interventions to maintain adequate nutritional status included to weigh as per physician's orders, provide and serve diet as ordered, monitor and record intakes for every meal, and provide supplements as ordered. Resident 25's weight record revealed the following recorded weights: May 3, 2023, at 3:12 PM - 133.2-pounds 395345 Page 7 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0692 May 4, 2023, at 12:53 PM - 133.8-pounds Level of Harm - Minimal harm or potential for actual harm May 12, 2023, at 9:20 PM - 133.8-pounds Residents Affected - Some May 18, 2023, at 3:42 PM - 116.8-pounds (significant weight loss of 16-pounds in one week and no re-weight obtained) May 23, 2023, at 10:52 AM - 116.8-pounds No weekly weight recorded. June 2, 2023, at 12:27 PM - 116.4-pounds June 12, 2023, at 5:24 PM - 118.4-pounds June 20, 2023, at 11:15 AM - 116.4-pounds June 26, 2023, at 1:44 PM - 118-pounds July 2, 2023, at 10:46 AM - 114.8-pounds On 7/10/2023 - changed to a monthly weight. Weekly weight obtained May 12, 2023, at 9:20 PM, at 117-pounds and was a significant weight loss of 16.8-pounds or 12.6% in one week. Another weight was obtained May 23, 2023 (5-days later), at 10:52 AM, at 116.8-pounds. A clinical record nutrition note completed by the RD on June 5, 2023, at 11:32 AM, revealed that the resident had a significant weight loss of 12.7% in one month. Current body weight at 116.4-pounds and a BMI of 26.1 - overweight. Diet was regular, puree, thin liquids and intake was good at 75-100% of meals. Dependent on staff for meals and supplemented with Boost pudding. The RD increased Boost pudding to three times per day and to continue weekly weights and monitor. There was no documented evidence that the physician was timely notified of Resident 25's significant weight loss in one week. Additionally, the clinical record revealed that the RD failed to timely identify and address Resident 25's significant weight loss until June 5, 2023, 15 days after the weight loss was identified to ensure timely review and revision of the resident's nutritional plan to assure the resident's degree and speed of weight loss was consistent with the resident's goals for weight status and maintenance of adequate nutritional paramaters. Interview with the facility's Registered Dietitian on July 27, 2023, at 10:15 AM, confirmed that Resident 25's significant weight loss was not timely acted upon and the physician wa not notified. Interview with the Director of Nursing (DON) on July 28, 2023, at 9:45 AM, confirmed that the facility failed to timely address significant weight loss to ensure timely review of the adequacy and continued appropriateness of planned nutritional regimens in maintaining adequate nutritional paramaters for these residents. 395345 Page 8 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0692 28 Pa Code 211.10 (a)(d) Resident care policies. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12 (d)(3)(5) Nursing services. Residents Affected - Some 395345 Page 9 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to provide trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 18 residents reviewed (Resident 45). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 45 was admitted to the facility on [DATE], with diagnoses that included depression. During the resident's stay in facility, it was noted that on September 27, 2022, Resident 45 received a diagnosis of Post Traumatic Stress Disorder (PTSD). The resident's current care plan, in effect at the time of review ending July 28, 2023, did not identify the resident PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. Interview with the Director of Nursing on July 27, 2023, at approximately 1:30 PM, confirmed the facility was unable to demonstrate that the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. 28 Pa Code 211.12 (d)(3)(5) Nursing services 395345 Page 10 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 18 residents sampled (Resident 52). Findings include: Review of clinical record of Resident 52 revealed that the resident was admitted to the facility on [DATE], with diagnoses including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Further review of Resident 52's clinical record revealed that the resident exhibited multiple behaviors, including yelling and making fun of his roommate, verbal behaviors towards staff, and throwing things at staff. Resident 52 was noted to have an increase in these behaviors beginning June 28, 2023, according to a review of progress notes. Review of Resident 52's care plan, initiated by the facility on July 12, 2022, indicated that the resident has a behavioral problem. However, this care plan did not address the resident's specific behavioral problems or symptoms. Interventions planned were that the resident enjoys talking to his sister and nephew, medications per physician orders, and to observe for mental status/behavioral changes when new medication started or with changes in dosage. Review of Resident 52 nursing progress notes in the resident's clinical record between June 28, 2023, and July 27, 2023, revealed that the resident also continued to consistently exhibit behaviors of yelling at staff, and yelling at roommate. There were no new or revised behavioral interventions for staff to employ added to the resident's care plan following the increase in behaviors beginning June 28, 2023, including yelling at, and making fun of his roommate, throwing things at staff, yelling at staff, which were continuing through end of survey July 28, 2023. According to Resident 52's clinical record, staff were to track the resident's behaviors on the resident's Medication Administration Record (MAR). A review of these MARs staff completed for Resident 52 from June 2023, through end of survey July 28, 2023, revealed that staff were not consistently tracking the resident's specific behaviors identified for monitoring that included delusions or hallucinations. There were no interventions identified for staff to use when the resident displayed the specific behaviors that were to be monitored and tracked. There was no documented evidence of the use of interventions or tracking of resident behaviors to identify any patterns (such as time of day, environmental stimuli, etc.), trends (frequency of similar behaviors) or other potential triggers. There was no evidence that the facility had developed and implemented plans to provide meaningful activities, which promote resident engagement based on the resident's customary routines, interests, preferences, to enhance the resident's mental health and well-being. 395345 Page 11 of 12 395345 07/28/2023 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0740 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing and Nursing Home Administrator on July 27, 2023, at approximately 1:30 PM verified that the facility was unable to provide evidence that the facility tracks resident behaviors and/or interventions used in response, as part of behavior management or modification plans. There is no mechanism in place to assess the effectiveness of any behavioral management approaches, diversional activities, or behavioral modification interventions noted on the resident's care plan. Residents Affected - Few 28 Pa. Code 211.12 (d)(3)(5) Nursing services 395345 Page 12 of 12