Health inspection·December 11, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility provided documentation, interview with staff and review of clinical record, it was determined that facility failed to ensure that require information to obtain an imaging study was submitted for one out of nine residents reviewed. (Resident R4) Residents Affected - Few Findings include: Review of Resident R4's clinical record that the resident was admitted to facility on January 27, 2023 with medical history of left basal ganglia, intraparenchymal hemorrhage (bleeding within brain parenchyma), status post craniectomy, stroke affecting right dominant side, cognitive communication deficit, encounter for surgical aftercare following surgery on the nervous system, depression, aphasia (difficulty speaking), dysphagia (difficulty swallowing),and gastrostomy status. Review of facility provided documentation revealed Resident R4 had left decompressive hemicraniectomy (neurosurgical procedure that removes part of the brain) completed prior to admission to facility, on January 2, 2023. On April 16, 2024, Resident R4 had consult regarding neurosurgery with recommendation for stealth CT ordered for prosthetic manufacturing. Further review of Resident R4's clinical record revealed that on May 7, 2024, nurse aide Employee E3, contacted Resident R4's insurance company regarding stealth CT scan, - many times to see if the scan had gotten approved. There is no accurate information at the moment because they never received the information as requested. I will re-fax the information to the insurance company. Further review of Resident R4's clinical record revealed that on May 24, 2024, nurse aide - Employee E3, contacted Resident R4's insurance company regarding CT scan of abdomen/pelvis with and without contrast, for which insurance company denied service and will not approve due to lack of medical information. Reviewed facility provided note from department of neurosurgery, dated April 26, 2024, which indicates that [Resident R4] requires a stealth CT scan to have a PEEK customized implant manufactured for his reconstructive cranioplasty Per phone interview with Resident R1's insurance company representatives on Wednesday, December 11, 2024 at 11:22 AM, and again at 11:35 AM, revealed that Resident R4 does not have any medical information submitted on his behalf in order to be approved for stealth CT scan and CT scan for abdomen/pelvis. Further interview with representatives revealed that insurance company requires Resident R4's prior imaging tests that show a need for further imaging, any current or completed treatment for the (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: 395865 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 395865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maplewood Nursing and Rehab Center 125 W Schoolhouse Lane Philadelphia, PA 19144 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)