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. (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 3 Event ID: 395828 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 395828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931 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)