Health inspection·December 30, 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 a facility policy, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that a resident was safely transfer via mechanical lift for one of four residents reviewed. (Resident R1) Findings include: Review of facility policy titled Mechanical Lift updated April 2023, revealed that initially the staff must review the resident's care plan to assess for any special needs of the resident and if warranted, assemble the equipment and supplies as needed. Further steps in the procedure to transfer a resident from a bed to a chair must follow guidelines of operation including that one nursing assistant or licensed nurse shall control the lift to prevent tilting, and lift bar from striking resident etc, the second nursing assistant or licensed nurse must be in control of the resident and repositioning. The general guidelines requires two nursing assistants and or two licensed staff will be required to perform the procedure . Review of Resident R1's Minimum Data Set (MDS- federal mandated assessment tool that measures health status of all residents) dated September 27, 2024 revealed that the resident was admitted to the facility on [DATE], with diagnoses of' atrophy (muscle mass loss due to neurogenic conditions), dysphasia (difficulty swallowing food or liquid), dementia (loss of memory, language, problem solving, nd other thinking abilities), and malnutrition (a condition that occurs when the body does not get the right amount of nutrients needs to function properly). Continue review of the MDS revealed that Resident 1 was totally dependent for transfers and required a wheelchair. Review of Resident R1's nursing evaluation dated December 21, 2024 revealed that the resident mobility was assessed as requiring a mechanical lift to transfer the resident from one surface to another by two staff. Observation outside Resident R1's room on December 30, 2024 at 11:05 a.m. revealed nurse aide, Employee E2 transferring Resident R1 by mechanical lift from bed to wheelchair. Employee E2 was the only employee in the room transferring the resident. Interview with Employee E2 at time of the above observation revealed that this employee was aware the the mechanical lift required a two person assists. Employee E2 stated that another employee was assisting but left the room. Review of facility inservice attendance record for transfers via hoyer lift dated September 2024 (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 12/30/2024 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)