Health inspection·October 9, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, document review, and resident and staff interviews, it was determined that the facility failed to provide an environment free from accident hazards to prevent potential incidents for one resident (Resident A1) out of eight sampled residents. Findings include: A review of Resident A1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included chronic pain and osteoarthritis (is inflammation of one or more joints and is the most common form of arthritis that affects joints in the hand, spine, knees, and hips). A review of the resident's quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) assessment dated [DATE], indicated that Resident A1's completed Brief Interview for Mental Status [(BIMS) a tool that assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information] score was 15 out of 15 (a score of 13 to 15 suggests intact cognition) and cognitively intact. Additionally, the MDS indicated that the Resident was able to independently ambulate with the use of a walker. A review of an investigation to an incident that occurred on August 31, 2024, at 8:30 PM, completed by Employee 1 (Registered Nurse [RN]), revealed that she was called to a Resident's room by a nurse who reported injury to ankle from slippage. Resident ambulated independently with her rolling walker to bedside drawer. While walking, she slipped on a wet floor caused by leaking window in her room. Resident denied falling and stated she was able to hold onto handle of her walker; however, she reported twisting her ankle during the event. RN assessment completed; right ankle noted to be tender to touch with mild edema. No visible bruises or deformity observed at the time of assessment. Resident pain rated 6/10 stated I was going over there to get my clothes and slipped on the water and hurt my leg. Ice applied to affected limb, medicated with acetaminophen 625 mg PO (by mouth), wet sign placed in room, and Resident encouraged to remain in bed and call for assistance. Bath blankets placed on windowsill and by the window to absorb water, work order submitted to maintenance department. MD contacted and ankle X-ray requested. Resident is her own responsible party, emergency contact notified, and a nursing communication sent to therapy. Further review of Resident A1's clinical record revealed negative x-ray results of her right ankle; however, moderate right ankle pain persisted with movement, touch, and weight bearing. Physician aware new orders for rest, ice, elevation/positioning. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395345 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 10/09/2024 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)