Health inspection·July 18, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and homelike resident environment on two of the three floors of the facility (the second, third floor and forth floor) and failed to maintain resident care equipment in clean and sanitary manner. Findings Include: An observation July 18, 2024 at 9 A.M. revealed a black substance on the air vent above the second floor nurses station, and two adjacent ceiling tiles. Observation on May 20, 2023, at 11:50 a.m. revealed that the floor of the second-floor community television and dining area was sticky floor and the feeling of resistance when lifting feet off of the floor to walk throughout the area. Dried liquid stains and food crumbs were observed in the refrigerator in the room. Liquid stains and food and paper debris were observed on the counter. Littered paper and food debris were observed in the drawers under the counter. Dried food and liquid stains were observed inside of the microwave. There was no lid on the garbage can, which contained trash. Dirt, debris and black scuff marks were observed on the floor in the second floor hall. A tour of the resident rooms on the second floor revealed that, with the exception of resident room [ROOM NUMBER], the floors in each resident room were coated with a thick brown residue and black scuff marks. Liquid stains, black scuff marks, and gouges were observed on the walls of the third floor hallway. Observation in resident room [ROOM NUMBER] revealed damaged floor tiles under the legs of the bed. An accummulation of a thick brown substance was observed along the baseboard of the floor running the perimeter of the third floor dining/activity room. An observation on July 18, 2024, at 12:00 P.M. in the fourth floor dining/activity room, revealed a wheelchair and broda chair, that were stained with dried white, brown, and yellow substances, dried stains and food were also observed the seats, wheels and axles of both the broda chair and the wheelchair. A thick black substance was observed at the floor baseboard running the perimeter room. In resident room [ROOM NUMBER], several damaged floor tiles were observed under the legs of the bed. Page 1 of 3 395345 395345 07/18/2024 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Dirt, debris and black scuff marks were observed on the floor of the fourth floor hallway. The floors of the resident rooms on the fourth floor were covered with a thick brown residue and black scuff marks. An interview with the Nursing Home Administrator on July 18, 2023, at approximately 2:00 p.m., confirmed that the residents' environment was to be maintained in a clean and homelike manner and resident care equipment was to be clean and sanitary. 28 Pa. Code 201.18 (e)(2.1) Management 395345 Page 2 of 3 395345 07/18/2024 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to properly dispose of garbage and refuse Residents Affected - Many Findings include: An observation July 18, 2024, at 8 AM and again at 12 P.M. revealed that the facility's two large trash dumpsters, containing bags garbage and trash, were not covered. The lids to both garbage dumpsters were observed opened during each observation. During an interview July 18, 2024 at approximately 2:30 P.M., the Nursing Home Administrator confirmed that the dumpsters lids should be closed. 28 Pa Code 201.18 (e)(2.1) Management 395345 Page 3 of 3