Health inspection·June 18, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined the facility failed to ensure a resident was invited to participate in the care planning process for one of 19 residents reviewed (Resident 42). Findings include: A clinical record review revealed Resident 42 was admitted to the facility on [DATE], with diagnosis to include vascular dementia (reduced blood flow to the brain leading to cognitive decline) and polyosteoarthritis (inflammation and pain of five or more joints of the body). A review of the annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 7, 2025, revealed that Resident 42 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact). During an interview on June 17, 2025, at 10:15 AM, Resident 42 stated she has not been invited to participate in the care planning process for development of her comprehensive person-centered care plan or attend any care plan meetings. A further review of the clinical record revealed no documented evidence that a care plan conference had been conducted since November 20, 2024. The clinical record revealed no documentation that Resident 42 had been invited to participate in the development or review of her comprehensive care plan. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on June 18, 2025, at 1:38 PM, both confirmed there was no documentation to show that a care plan conference had been held for Resident 42 since November 2024 or that Resident 42 had been invited to participate in the care planning process. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12(d)(3) Nursing services. Page 1 of 2 395345 395345 06/18/2025 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 the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 19 residents reviewed (Resident 18). Residents Affected - Few Findings include: A review of Resident 78's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Depression. Resident 18 had been newly diagnosed on [DATE] with Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). The resident's current care plan, in effect at the time of review on June 16, 2025, did not identify the resident's 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 Nursing Home Administrator on June 18, 2025, at 1:00 p.m., confirmed the facility was unable to demonstrate 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 2 of 2