Health inspection·September 3, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve resident complaints and grievances expressed during Resident Council meetings and written grievances, including those voiced by for two of ten residents reviewed. (Residents 1 and 2). Findings include:A review of the facility's Grievance Policy last revised on May 27, 2025, revealed that the resident has the right to voice grievances to the Center or other agency or entity (for example the State Ombudsman) that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The Nursing Home Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. All grievances, complaints or recommendations stemming from residents or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. A review of the Resident Council meeting minutes dated August 28, 2025, revealed repeated concerns that call bells were not being answered timely. A review of a written grievance from Resident 1, dated August 28, 2025, revealed that the resident stated she had to wait a long time for staff to respond to the call bell to meet her needs. The documented facility action was to conduct call bell audits. Resident 1 refused to sign the grievance as resolved, stating I am still waiting too long. Facility call bell audits were conducted from August 29, 2025, through September 1, 2025, and the grievance was marked by the NHA as completed and resolved on September 2, 2025. During an interview on September 3, 2025, at 11:00 AM, Resident 1 (who is cognitively intact, able to understand and communicate clearly) stated that staff response times to her call bell continued to be greater than 30 minutes on the second and third shifts. She reported she had voiced grievances both verbally and in writing at the August 2025 Resident Council Residents Affected - Few (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 09/03/2025 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)