Health inspection·May 13, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer treatments were provided to prevent infection for one of eight residents reviewed (Resident 2). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 2, 2025, revealed that the resident was cognitively impaired, required assistance with care, had diagnoses that included quadriplegia (condition that causes a complete or severe loss of motor function in all four limbs), a traumatic brain injury, had no unhealed pressure ulcers (wounds caused by pressure), and had moisture-associated skin damage. A nursing note for Resident 2, dated March 29, 2025, at 10:42 p.m. revealed that the registered nurse was called to assess the resident for a reported new open area measuring 1.0 centimeters (cm) x 0.5 cm. Intervention to prevent further occurrences was to place blue incontinent pads and to cleanse wound with wound cleanser and apply Thera honey topically to lower right buttock wound and cover with adhesive Opti foam (an absorptive dressing bordered with adhesive) daily and as needed for soilage and displacement. The Certified Registered Nurse Practitioner (CRNP) was notified of a new open area to right lower inner buttock. A Wound Healing consult note for Resident 2, dated April 2, 2025, revealed that the right buttock area was moisture-associated skin damage (inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus). The provider's plan was to continue the medihoney at this time as the area was progressing fairly well. Physician's orders for Resident 2, dated April 2, 2025, included an order to cleanse the right buttocks with wound cleanser, pat dry then apply medihoney to the area, apply cover with adhesive border foam dressing (an absorptive dressing bordered with adhesive) once a day and as needed. A weekly CRNP Wound Healing consult note for Resident 2, dated April 8, 2025, indicated that the right buttock area appeared worse. The provider's plan was to change the treatment. Cleanse the wound, pat dry, apply Hydrofera blue (a wound treatment), and cover with foam dressing daily and as needed. There was no documented evidence in Resident 2's clinical record to indicate that the new treatment of Hydrofera blue was intiated. A nursing progress note for Resident 2, dated April 10, 2025, indicated that the resident was seen at bedside for wound rounds. The area to the right buttock has worsened. New orders were given and Page 1 of 3 395828 395828 05/13/2025 Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident's responsible party was informed of the worsening wound and new orders. Physician's orders for Resident 2, dated April 10, 2025, included an order to cleanse the right buttocks with wound cleanser, pat dry then apply Hydrofera blue, apply cover with a foam dressing once a day and as needed. The April, 2025 Treatment Administration Record (TAR) for Resident 2 indicated that the wound treatment orders from April 8, 2025, were not changed until April 10, 2025. Interview with the Director of Nursing and Registered Nurse 1 (a unit manager that usually rounds with the wound consultant) on May 13, 2025, at 3:08 p.m. confirmed that she did not update the orders for Resident 2's worsening wound in a timely manner, and the resident received the wrong treatment. 28 Pa. Code 211.12(d)(5) Nursing Services. 395828 Page 2 of 3 395828 05/13/2025 Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on resident and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties. Residents Affected - Some Findings include: Interview with Resident 3 on May 13, 2025, at 12:24 p.m. revealed that there are times when their meals were served on styrofoam plates with plastic silverware. This occurs on random days with no explanation. Interview with Resident 5 on May 13, 2025, at 12:26 p.m. revealed that there were times when they get their food on styrofoam plates with plastic silverware only it happens randomly with no explanation. Interview with Resident 7 on May 13, 2025, at 11:40 a.m. revealed that there were times when they get their food on styrofoam plates with plastic silverware, about fifty percent of the time, due to staffing. Resident 7 revealed that they had plastic silverware just this morning for breakfast. Interview with the Assistant Nursing Home Administrator on May 13, 2025, at 3:12 p.m. confirmed that plastic silverware was provided to the residents this morning for the breakfast meal due to low staffing in the kitchen. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code 201.20(b) Staff Development. 395828 Page 3 of 3