Health inspection·June 16, 2025

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician-ordered 15-minute safety checks were completed for one of 10 resident's reviewed (Resident 5). Residents Affected - Few Findings include: The facility's policy for safety checks dated, December 30, 2024, revealed that if a resident is on 15 or 30-minute safety checks, the staff member much have visual of the resident during each timeframe and utilize the observation/monitoring tool to document completing the observation and the status of the resident to ensure the resident is safe. The facility's policy for change of shift report, dated December 30, 2024, revealed that report is to be given in a clear and concise manner that may include observations that would be helpful to personnel caring for the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 5, dated June 5, 2025, revealed that the resident was usually understood and sometimes could understand others, was cognitively impaired, was independent with daily care needs, and had a diagnosis of anxiety. A psychiatry note for Resident 5, dated June 5, 2025, revealed that the resident was on one-on-one observation for behaviors that included attempting to get women to go into his room and following women on the unit. A nursing note for Resident 5, dated June 9, 2025, at 6:55 p.m., revealed that the resident remained on 15-minute checks. Physician's orders for Resident 5, dated June 7, 2025, included an order for the resident to be placed on 15-minute checks. Observation of Resident 5 on June 16, 2025, at 10:23 a.m. until 11:07 a.m. revealed that the resident was in his room resting on his bed and no staff conducted 15-minute safety checks on the resident. Interview with Nurse Aide 1 at 11:08 a.m. revealed that she just walked into his room to drop something off for his roommate and was unaware that the resident was on 15-minute safety checks and that it was not provided to her during shift report. It was her first day as an agency nurse and she was unable to log into the computer all day. Page 1 of 3 395828 395828 06/16/2025 Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931

F 0684 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on June 16, 2025, at 12:07 p.m. indicated that staff should provide a thorough change of shift report that included the fact that Resident 5 was on 15-minute checks, and confirmed that staff should have been visualizing the resident every 15 minutes to ensure safety per physician's orders. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395828 Page 2 of 3 395828 06/16/2025 Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility , as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for handling linen. Residents Affected - Few Findings include: The facility's environmental services policy for laundry, dated December, 30, 2024, indicated that linens will be handled, transported, and processed in a manner which reduces the risk of contamination or cross-contamination in a safe sanitary manner. facility will handle all used linen as potentially contaminated and use standard precautions when handling, sorting or rinsing. Soiled linens will be bagged at point of care and placed in a soiled linen container in the soiled utility room or deposited into a laundry chute. Observations on June 16, 2025, at 10:17 a.m. revealed that there was soiled linen and a soiled brief lying on the floor inside a resident room. There was no staff in the room or in the hallway. Interview with Registered Nurse 2 on June 16, 2025, at 10:30 a.m. confirmed that the soiled linen and brief should not be on the floor, it should have been bagged and placed in the soiled linen container and taken to the dirty utility room. Interview with the Director of Nursing on June 16, 2025, at 12:06 p.m. confirmed that the soiled linen and brief should not have been on the floor and that staff should place all laundry in bags and take them to the dirty utility room. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395828 Page 3 of 3