Health inspection·May 15, 2024

F 0574 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some which the facility can assist a beneficiary with a plan change. The need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that that the beneficiary and/or the representative understand the information. The need to obtain an attestation signed by the facility staff member that assisted with the change in enrollment, attesting that the beneficiary or representative requested the change and that the beneficiary or representative (as applicable) received and understood the minimum required information listed above. In cases where beneficiaries request disenrollment from PACE, LTC facilities that are contracted with PACE organizations should work directly with the PACE organization and the participant's interdisciplinary team to ensure the PACE participant receives the information required under the PACE regulations and to coordinate the transition of care, including as specified in their contract requirements. If a LTC facility cannot provide documentation of a beneficiary's request to change enrollment, this may suggest that the enrollment action was not initiated by the beneficiary or their legal representative and therefore was not legally valid. Lastly If the facility has the beneficiary sign documentation regarding their understanding of an enrollment change, CMS will expect to find that the beneficiary's assessed cognitive function also supports an ability to understand this type of information. If CMS becomes aware of enrollment actions that the beneficiary alleges were taken without their request, consent, knowledge, and/or complete understanding, CMS will expect the facility to provide the above noted documentation to support that it appropriately assisted the beneficiary with their choice to change coverage, including that the beneficiary's cognitive function supports such decision-making. A review of Resident CR1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes, peripheral vascular disease, and bilateral below the knee amputations. Upon admission the resident's primary insurance payer was noted to be Aetna Medicare Advantage Plan. On February 1, 2024, the resident's primary insurance payer was changed to traditional Medicare with Medicaid pending. Review of documentation dated [DATE], completed by the facility's Business Office Manager (BOM), revealed that on [DATE], the BOM spoke with Resident CR1 about transitioning to straight Medicare since he will be long term. Went over how the transition will benefit him here at the facility regarding his therapy and possibly getting more time. According to the documentation, the resident chose to disenroll in his Aetna MCA and give straight MCA [Medicare] a try. A review of a facility form entitled Medicare Advantage Disenrollment Form dated [DATE], revealed a request to disenroll the resident from the resident's Medicare Advantage plan so that the resident may be covered under original Medicare prescription plan (Part D) benefits. Resident CR1 no longer resides at the facility, he expired at the hospital on February 13, 2024. A review of Resident 13's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (disorder which causes extreme mood swings that include emotional highs and lows), aphasia (a disorder which that affects how one communicates. It can impact speech, as well as the way you write and understand both spoken and written language), and high cholesterol. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395345 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0574 Effective [DATE], the resident's stay at the facility was paid by Medicaid. Level of Harm - Minimal harm or potential for actual harm A quarterly MDS dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 15. Residents Affected - Some A review of a facility form entitled Medicare Advantage Disenrollment Form dated February 13, 2024, revealed a request to disenroll the resident from the resident's GHP Medicare Advantage plan so that the resident will be eligible for Medicare Part A and Part B benefits. covered under original Medicare prescription plan (Part D) benefits. Review of documentation dated [DATE], completed by the facility's BOM, revealed that on February 13, 2024, the BOM spoke with Resident 13 and the resident's daughter/RP about transitioning to straight Medicare since we recently got her approved for Medicaid and went over how the transition will benefit her here at the facility pertaining to her therapy and possibly getting more time. According to the documentation, the resident chose to disenroll from her GHP Medicare Advantage Plan to try out straight Medicare. Documentation dated [DATE], completed by the BOM, indicated that Resident 13 is happy with her choice and stated that she has been getting more therapy time. According to the note, Resident 13 will be transitioning home with waiver services and intends not to reenroll in the Medicare Advantage Plan. Review of Resident 50's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included congestive heart failure, cognitive communication deficit (communication problems that can occur after a brain injury, stroke, or other neurological damage. These deficits can affect many aspects of thinking and social skills including difficulty concentrating on conversations, or missing important information), and aphasia following a stroke. A quarterly MDS dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 15. A review of a facility form entitled Medicare Advantage Disenrollment Form dated [DATE], revealed a request to disenroll Resident 50 from the resident's Aetna Medicare Advantage plan so that the resident will be eligible for Medicare Part A and Part B benefits and for the resident to be enrolled in a Medicare Drug Plan effective [DATE]. Review of documentation dated [DATE], completed by the facility's BOM, revealed that on [DATE], the BOM spoke with Resident 50 about transitioning to straight Medicare at the facility since the resident intended to remain in the facility long-term. According to the documentation, the BOM went over how the transition could benefit her here at the facility regarding her therapy and possibly getting more time. The BOM further discussed that we can always reenroll her in Aetna MCA if she chooses to do so. Review of Resident 59's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses which included heart disease, diabetes, and chronic post-traumatic stress disorder. A quarterly MDS dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 15. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395345 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0574 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of a facility form entitled Medicare Advantage Disenrollment Form dated February 15, 2024, revealed a request to disenroll Resident 59 from the resident's GHP Medicare Advantage plan so that the resident will be eligible for Medicare Part A and Part B benefits and for the resident to be enrolled in a Medicare Drug Plan effective [DATE]. Review of documentation dated [DATE], completed by the facility's BOM, revealed that on February 15, 2024, the BOM spoke with the resident about transitioning to straight Medicare. According to the documentation, the resident is a long-term resident who is off and on part B services often. The BOM went over how the transition will benefit him here at the facility regarding his therapy and possibly getting more time and also cut down on submitting for auths [authorizations] and having a specific time range to work with. We spoke about referrals and his doctors, and I let him know that with Medicare, referrals aren't usually needed and Medicare you can go to any doctor in the U.S. and he will not have a problem. He chose to disenroll in his GHP MCA and give straight Medicare a try. Review of Resident 61's clinical record revealed admission to the facility on [DATE], with diagnoses which included cognitive communication deficit, dementia, and hypertension. A quarterly MDS dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 15. A review of a facility form entitled Medicare Advantage Disenrollment Form dated February 15, 2024, revealed a request to disenroll Resident 61 from the resident's GHP Medicare Advantage plan so that the resident will be eligible for Medicare Part A and Part B benefits and for the resident to be enrolled in a Medicare Drug Plan effective [DATE]. Review of documentation dated [DATE], completed by the facility's BOM, revealed that on February 15, 2024, the BOM spoke to Resident 61 about transitioning to straight Medicare at the facility since she would be staying long term. The BOM further stated that she went over how the transition will benefit her here, especially since she is off and on her part B services at the facility regarding her therapy and possibly getting more time without having to struggle with auths [authorizations] and time frames. Review of Resident 75's clinical record revealed admission to the facility on [DATE], with diagnoses which included aphasia following a stroke, dementia, and COPD. A quarterly MDS dated [DATE], revealed that the resident was moderately cognitively impaired with a BIMS score of 11. A review of a facility form entitled Medicare Advantage Disenrollment Form dated [DATE], revealed a request to disenroll Resident 75 from the resident's Aetna Medicare Advantage plan so that the resident will be eligible for Medicare Part A and Part B benefits and for the resident to be enrolled in a Medicare Drug Plan effective [DATE]. Review of documentation dated [DATE], completed by the facility's BOM, revealed that on [DATE], the BOM spoke with Resident 75 about transitioning to straight Medicare due to her often voicing not getting enough therapy time. The BOM went over how the transition will benefit her here at the facility regarding her therapy and possibly getting more time as she wished. She chose to disenroll in her Aetna MCA and give straight MCA a try. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395345 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0574 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of clinical record revealed admission to the facility on [DATE], with diagnoses which included COPD, diabetes, and hypertension. A quarterly MDS dated [DATE], revealed the resident was cognitively intact with a BIMS score of 15. A review of a facility form entitled Medicare Advantage Disenrollment Form dated [DATE], revealed a request to disenroll Resident 81 from the resident's GHP Medicare Advantage plan so that the resident will be eligible for Medicare Part A and Part B benefits and for the resident to be enrolled in a Medicare Drug Plan effective February 1, 2024. Review of documentation dated [DATE], completed by the facility's BOM, revealed that on [DATE], about transitioning to straight Medicare at the facility since he will be a long-term resident. According to the documentation, the BOM discussed how the transition will benefit him here at the facility regarding his therapy, getting more skilled time part B services and avoiding having to submit auths and also being capable to monitor progress in-house. These changes in Medicare health plans were initiated by the facility and not by the beneficiary or their representative. Interview with the Nursing Home Administrator and Business Office Manager on [DATE], confirmed that the facility did not have any policies or procedures in place that outline the process of assisting beneficiaries and their representatives with changing their Medicare health plans. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1. The facility policy and procedure was updated. The residents identified, will be contacted to review verbally and in writing their current plans. The facility will reconnect with those residents not capable of making their own decisions. 2. Nursing Home Administrator or designee will conduct an initial audit to validate that any changes made to current residents Medicare Health Plans follow the facility's policy. 3. Nursing Home Administrator or designee will re-educate the Business office manager and Social Service Director regarding Medicare Health Plan Enrollment Policy and Procedure. 4. Nursing Home Administrator or designee will conduct weekly random audits for four weeks and then monthly audits for two months thereafter to validate that current residents who have recently elected to change their Medicare Health Plan is following the facility policy. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395345 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0574 necessary. Level of Harm - Minimal harm or potential for actual harm The facility's completion date was [DATE], and verified during survey completed [DATE]. 28 Pa. Code 201.29 (a)(c) Resident rights Residents Affected - Some 28 Pa. Code 201.18 (b)(1)(2)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395345 If continuation sheet Page 6 of 6