Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it
was determined that the facility failed to ensure that residents were free from abuse or neglect for 14 of 14
residents reviewed (Residents 1,2,3,4,5,6,7,8,9,10,11,12,13 and 14). This deficiency is being cited as past
non-compliance. Findings include:The facility's policy regarding abuse, neglect, and exploitation, dated
December 30, 2024, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of
residents, or misappropriation of resident property by anyone. Abuse was defined as the willful infliction of
injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental
anguish. Abuse also includes the deprivation by an individual including a caretaker of goods or services
that are necessary to attain or maintain physical, mental, and psychological well-being. Neglect was
defined as the failure of the facility, its employees, or services providers to provide goods and services to a
resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Facility
investigation documents, dated June 18, 2025, revealed that Agency Licensed Practical Nurse 1, did not
give multiple residents on the 3rd floor their medications between the hours of 7:00 p.m. and 3:00 a.m. The
facility's Electronic Medication Administration Record (EMAR) went down, causing a short system outage.
Registered Nurse 2 called the nursing units and there were no reported issues except for the system being
down. Registered Nurse 2 placed a ticket in for IT to let them know of the outage. Licensed Practical Nurse
1 told Registered Nurse 2 that she did not give any of the medications because the system was down and
stated, what else was she supposed to do. The Director of Nursing arrived at the facility around 5:00 a.m.
and spoke with Licensed Practical Nurse 2 about the incident. Licensed Practical Nurse 2 said the system
went down and did not know what else could be done. The Director of Nursing told Licensed Practical
Nurse 2 that she should have notified the RN supervisor as soon as she realized she was unable to pass
the medications so a plan could have been put into place to address the issue instead of just neglecting to
give them. A whole house audit with medication compliance was checked to identify which residents did not
receive medications. The whole house audit revealed that 14 residents identified on 3rd floor did not receive
physician ordered medications between 7:00 p.m. and 3:00 a.m. The medical director was notified, as well
as Certified Registered Nurse Practitioners (CRNP-a registered nurse (RN) who has advanced education
and clinical training in a health care specialty area) 3 and 4. Nursing assessments were completed on all of
the residents with no adverse reactions noted. All responsible parties were notified of medication
omissions. Local Township Police and Adult Protective Services were notified, and documentation was
completed on each resident. The agency that Licensed Practical Nurse 1 was employed by was made
aware of the incident and were made aware that she will no longer be permitted to work at the facility. The
Pennsylvania State Licensing Board of Nursing was also notified of the incident, and a Provider Bulletin 22
report was completed.Physician's orders for Resident 1, dated October 24,
(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 6
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
07/02/2025
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
2024, included an order for the resident to receive 20 milligrams (mg) of Oxycodone (a controlled opioid
pain medication) every six hours for pain. The Medication Administration Record (MAR) for June 2025,
revealed that on June 18, 2025, Licensed Practical Nurse 1 documented that due to the system being down
she did not administer the 2:00 a.m. dose of Oxycodone.Current physician's orders for Resident 2 included
orders for the resident to receive one application of ammonium lactate lotion 12% twice a day for dry skin; 1
drop of artificial tears 1.4% in each eye three times a day for dry eyes; 40 mg of atorvastatin at bedtime for
hyperlipidemia (elevated lipids in the blood); 1 drop of brimonidine 0.2% to right eye three times a day for
glaucoma (an eye condition that damages the optic nerve); one application of calmoseptine ointment
0.44-20.6% to both sides of the buttocks twice a day for skin protection; 1 drop of dorzolamide 2% drops to
the right eye twice a day for glaucoma; 5 mg of Eliquis (blood thinner) twice a day for blood clot prevention;
300 mg of gabapentin three times a day for pain; 5-325 mg of Norco (controlled opioid pain medication)
twice a day for pain; 250 mg of Keppra twice a day for seizure prevention; and 8.6 mg of senna twice a day
for constipation. The MAR for June 2025 revealed that Licensed Practical Nurse 1 documented that due to
the system being down she did not give the 7:00-11:00 p.m. doses of ammonium lactate lotion, artificial
tears, atorvastatin, brimonidine, calmoseptine, dorzolamide, Eliquis, gabapentin, Norco, Keppra and
senna.Current physician's orders for Resident 3 included orders to receive 10 mg of cyclobenzaprine twice
a day for muscle spasms; 500 mg of levetiracetam twice a day for seizures; 45 mg of mirtazapine at
bedtime for depression; 8 mg of ramelteon at bedtime for insomnia (difficulty sleeping); and 1 gram (gm) of
sucralfate for GERD (gastroesophageal reflux disease). The MAR for June 2025 revealed that on June 17,
2025, Licensed Practical Nurse 1 documented that due to the system being down she did not give the
7:00-11:00 p.m. doses of cyclobenzaprine, levetiracetam, mirtazapine, ramelteon and sucralfate.Current
physician's orders for Resident 4 included orders for the resident to receive 20 mg of baclofen three times a
day for muscle spasms; 650 mg of Tylenol every 6 hours for pain; 1 drop of alphagan 0.1 % in both eyes for
glaucoma; 5 mg of diazepam at bedtime for anxiety; and 25 mg of promethazine every 6 hours for allergies.
The MAR for June 2025 revealed that on June 17, 2025, Licensed Practical Nurse 1 documented that due
to the system being down she did not give the 8:00 p.m. to 12:00 a.m. doses of baclofen, Tylenol, alphagan,
diazepam and promethazine.Current hysician's orders for resident 5 included orders for the resident to
receive 500 mg of cipro (antibiotic) twice a day for a skin infection; one application of hydrocortisone 1%
cream twice a day for skin care; 5 mg of memantine twice a day for Alzheimer's disease (a progressive
neurodegenerative disorder that gradually impairs memory and thinking); a probiotic (supplement) twice
daily for preventative measures related to antibiotics usage; and one application of zinc oxide paste 1% for
skin care. The MAR for June 2025 revealed that on June 17, 2025, Licensed Practical Nurse 1 documented
that due to the system being down she did not give the 7:00 p.m. to 11:30 p.m. doses of cipro,
hydrocortisone crem, memantine, probiotic and zinc oxide paste.Current physician's orders for Resident 6
included orders for the resident to receive 50 mg of tramadol every 6 hours for pain and 325 mg of Tylenol
every 6 hours for pain. The MAR for June 2025 revealed that on June 17, 2025, Licensed Practical Nurse 1
documented that due to the system being down she did not give the 12:00 a.m. doses of tramadol and
Tylenol.Current physician's orders for Resident 7 included orders for the resident to receive one application
of A & D ointment twice a day for skin care; 500 mg of Tylenol every 8 hours for pain ; one puff of Advair
250-50 micrograms (mcg)/dose twice a day for difficulty breathing; 40 mg of atorvastatin at bedtime for
heart disease; 5 mg of baclofen three times a day for muscle spasms; 260 mg calcium carbonate twice a
day for supplement; 12.5-50-200 mg of carbidopa-levodopa-entacapone three times a day for Parkinson's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395828
If continuation sheet
Page 2 of 6
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
07/02/2025
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
disease; 200 mg of entacapone three times a day for Parkinson's disease; 25 mg of hydroxyzine HCL at
bedtime for anxiety; 20 units of Insulin glargine 100 units/1 milliliter (ml) subcutaneously (injected just under
the skin into the fatty layer) at bedtime for type 2 diabetes mellitus; 50 mg of lamotrigine at bedtime for
bipolar disorder; 15 mg of mirtazapine at bedtime for depression; Novolin insulin (an intermediate-acting
insulin) subcutaneously per sliding scale (the amount of insulin is based on the result of a fingerstick blood
sugar test) that included calling the MD if the blood sugar is below 60, giving 0 units for a blood sugar of
1-150 mg/dL, 2 units of insulin for a blood sugar of 151-180 mg/dL, 4 units for a blood sugar of 181-220
mg/dL, 6 units for a blood sugar of 221-260 mg/dL, 8 units for a blood sugar of 261-300 mg/dL, 10 units for
a blood sugar of 301-350 mg/dL, 12 units for blood sugar of 351-400 mg/dL, 14 units for a blood sugar of
401-450 mg/dL, 16 units for a blood sugar of 451-500 mg/dL and if blood sugar is greater than 500, call MD
before meals and at bedtime for type 2 diabetes; 40 mg of paroxetine at bedtime for depression; 10 mg of
propranolol three times a day for coronary artery disease; 8.6-50 mg of Senna at bedtime for constipation;
and 100 mg topiramate at bedtime for bipolar disorder. The MAR for June 2025 revealed that on June 17,
2025, Licensed Practical Nurse 1 documented that due to the system being down she did not give the 7:00
p.m. to 11:00 p.m. doses of A&D ointment, Tylenol, Advair, baclofen, calcium carbonate,
carbidopa-levodopa-entacapone, entacapone, hydroxyzine, insulin glargine, lamotrigine, mirtazapine,
Novolin insulin, paroxetine, propranolol, senna and topiramate.Current physician's orders for Resident 8
included an order for the resident to receive 5 mg of Oxycodone every six hours for pain. The MAR for June
2025 revealed that on June 17, 2025, Licensed Practical Nurse 1 documented that due to the system being
down she did not give the 12:00 a.m. dose of Oxycodone.Current physician's orders for Resident 9 included
orders for the resident to receive 20 mf of atorvastatin at bedtime for hyperlipidemia (elevated lipids in the
blood); 25-100 mg of carbidopa-levodopa three times a day for Parkinson's disease; 0.5 mg of clonazepam
three times a day for anxiety; 325 mg of ferrous sulfate twice a day for anemia; and 1 gm of icosapent twice
a day for hyperlipidemia (elevated lipids in the blood). The MAR for June 2025 revealed that on June 17,
2025, Licensed Practical Nurse 1 documented that due to the system being down she did not give the 7:00
p.m. to 11:00 p.m. doses of atorvastatin, carbidopa-levodopa, clonazepam, ferrous sulfate and
icosapent.Current physician's orders for Resident 10 included orders for the resident to receive one
application of calmoseptine ointment 0.44-20.6% four times a day for skin care. The MAR for June 2025
revealed that on June 17, 2025, Licensed Practical Nurse 1 documented that due to the system being down
she did not give the 8:00 p.m. dose of calmoseptine.Current physician's orders for Resident 11 included an
order for the resident to receive 5 mg of Oxycodone every 6 hours for pain. The MAR for June 2025
revealed that on June 17, 2025, Licensed Practical Nurse1 documented that due to the system being down
she did not give the 12:00 a.m. dose of oxycodone.Current physician's orders for Resident 12 included an
order for the resident to receive 25 mg of pregabalin every 8 hours for nerve pain. The MAR for June 2025
revealed that on June 17, 2025, Licensed Practical Nurse 1 documented that due to the system being down
she did not give the 12:00 a.m. dose of pregabalin.Current physician's orders for Resident 13 included an
order for the resident to receive 10 mg of Oxycodone every 6 hours for pain. The MAR for June 2025
revealed that on June 17, 2025, Licensed Practical Nurse 1 documented that due to the system being down
she did not give the 12:00 a.m. dose of oxycodone.Current physician's orders for Resident 14 included an
order for the resident to receive 3 ml of albuterol 0.5 mg-3 mg every 4 hours for COPD (chronic obstructive
pulmonary disease); 80 mg of atorvastatin at bedtime for hyperlipidemia; 5 mg of Eliquis twice a day for
atrial fibrillation (a type of irregular heartbeat); 600 mg of guaifenesin twice a day for congestion; 25 mg
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395828
If continuation sheet
Page 3 of 6
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
07/02/2025
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
of metoprolol twice a day for elevated blood pressure; and 500 mg of calcium carbonate at bedtime for
GERD. The MAR for June 2025 revealed that on June 17, 2025, Licensed Practical Nurse 1 documented
that due to the system being down she did not give the 8:00 p.m. to 12:00 a.m. doses of albuterol,
atorvastatin, Eliquis, guaifenesin, metoprolol and calcium carbonate.An interview with the Director of
Nursing on July 2, 2025, at 1:00 p.m. confirmed that the facility's investigation was completed on June 19,
2025, and that neglect was substantiated.Following the incident/investigation on June 18, 2025, the facility's
corrective actions included:Nursing staff were educated on abuse and neglect, medication administration
and how to access the backup electronic medical record system. All education was completed June 19,
2025.Audits to monitor and maintain ongoing compliance with abuse and neglect prevention, medication
administration and the function of the electronic medical record system and were conducted weekly for four
weeks then monthly for two months.The results of these audits will be brought to Quality Assurance
Performance Improvement committee for further analysis and corrective actions if necessary.A review of
the facility's corrective actions revealed that they were in compliance with F600 on June 19, 2025.Interview
with the Director of Nursing on July 2, 2025 at 1:00 p.m. revealed staff education was completed and
ongoing audits are to be discussed during the monthly Quality Assurance (QA) meeting.28 Pa. Code
201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(c)(d)
Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services
Event ID:
Facility ID:
395828
If continuation sheet
Page 4 of 6
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
07/02/2025
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)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of policies and clinical records, as well as staff and resident interviews, it was determined
that the facility failed to provide medication as ordered by the physician, resulting in significant medication
errors for three of 14 residents reviewed (Residents 2, 7 and 14). This deficiency is being cited as past
non-compliance. Findings include:The facility's policy for medication administration, dated December 30,
2024, indicated that medication would be administered according to physician orders.Facility investigation
documents, dated June 18, 2025, revealed that Agency Licensed Practical Nurse 1, did not give multiple
residents on the 3rd floor their medications between the hours of 7:00 p.m. and 3:00 a.m. The facility's
Electronic Medication Administration Record (EMAR) went down, causing a short system outage.
Registered Nurse 2 called the nursing units and there were no reported issues except for the system being
down. Registered Nurse 2 placed a ticket in for IT to let them know of the outage. Licensed Practical Nurse
1 told Registered Nurse 2 that she did not give any of the medications because the system was down and
stated, what else was she supposed to do. The Director of Nursing arrived at the facility around 5:00 a.m.
and spoke with Licensed Practical Nurse 2 about the incident. Licensed Practical Nurse 2 said the system
went down and did not know what else could be done. The Director of Nursing told Licensed Practical
Nurse 2 that she should have notified the RN supervisor as soon as she realized she was unable to pass
the medications so a plan could have been put into place to address the issue instead of just neglecting to
give them. A whole house audit with medication compliance was checked to identify which residents did not
receive medications. The whole house audit revealed that 14 residents identified on 3rd floor did not receive
physician ordered medications between 7:00 p.m. and 3:00 a.m. The medical director was notified, as well
as Certified Registered Nurse Practitioners (CRNP-a registered nurse (RN) who has advanced education
and clinical training in a health care specialty area) 3 and 4. Nursing assessments were completed on all of
the residents with no adverse reactions noted. All responsible parties were notified of medication
omissions. Local Township Police and Adult Protective Services were notified, and documentation was
completed on each resident. The agency that Licensed Practical Nurse 1 was employed by was made
aware of the incident and were made aware that she will no longer be permitted to work at the facility. The
Pennsylvania State Licensing Board of Nursing was also notified of the incident, and a Provider Bulletin 22
report was completed. The omission of medications resulted in significant medication errors for Residents
2, 7 and 14.Current physician's orders for Resident 2 included orders for the resident to receive 5 mg of
Eliquis (blood thinner) twice a day for blood clot prevention; 300 mg of gabapentin three times a day for
pain; 5-325 mg of Norco (controlled opioid pain medication) twice a day for pain; and 250 mg of Keppra
twice a day for seizure prevention. The MAR for June 2025 revealed that Licensed Practical Nurse 1
documented that due to the system being down she did not give the 7:00-11:00 p.m. doses of Eliquis,
gabapentin, Norco, and Keppra Current physician's orders for Resident 7 included orders for the resident to
receive 12.5-50-200 mg of carbidopa-levodopa-entacapone three times a day for Parkinson's disease; 200
mg of entacapone three times a day for Parkinson's disease; 20 units of Insulin glargine 100 units/1 milliliter
(ml) subcutaneously (injected just under the skin into the fatty layer) at bedtime for type 2 diabetes mellitus;
and Novolin insulin (an intermediate-acting insulin) subcutaneously per sliding scale (the amount of insulin
is based on the result of a fingerstick blood sugar test) that included calling the MD if the blood sugar is
below 60, giving 0 units for a blood sugar of 1-150 mg/dL, 2 units of insulin for a blood sugar of 151-180
mg/dL, 4 units for a blood sugar of 181-220 mg/dL, 6 units for a blood sugar of 221-260 mg/dL, 8 units for a
blood sugar of 261-300 mg/dL, 10 units for a blood sugar of 301-350 mg/dL, 12 units for blood sugar of
351-400
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395828
If continuation sheet
Page 5 of 6
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
07/02/2025
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)
F 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
mg/dL, 14 units for a blood sugar of 401-450 mg/dL, 16 units for a blood sugar of 451-500 mg/dL and if
blood sugar is greater than 500, call MD before meals and at bedtime for type 2 diabetes. The MAR for
June 2025 revealed that on June 17, 2025, Licensed Practical Nurse 1 documented that due to the system
being down she did not give the 7:00 p.m. to 11:00 p.m. doses of carbidopa-levodopa-entacapone,
entacapone, insulin glargine and Novolin insulin.Current physician's orders for Resident 14 included an
order for the resident to receive 5 mg of Eliquis twice a day for atrial fibrillation (a type of irregular
heartbeat). The MAR for June 2025 revealed that on June 17, 2025, Licensed Practical Nurse 1
documented that due to the system being down she did not give the 7:00 p.m. to 11:30 a.m. dose Eliquis.An
interview with the Director of Nursing on July 2, 2025, at 1:00 p.m. confirmed that the facility's investigation
was completed on June 19, 2025, and that significant medication errors did occur.Following the
incident/investigation on June 18, 2025, the facility's corrective actions included:Nursing staff were
educated on abuse and neglect, medication administration and how to access the backup electronic
medical record system. All education was completed June 19, 2025.Audits to monitor and maintain ongoing
compliance with abuse and neglect prevention, medication administration and the function of the electronic
medical record system and were conducted weekly for four weeks then monthly for two months.The results
of these audits will be brought to Quality Assurance Performance Improvement committee for further
analysis and corrective actions if necessary.A review of the facility's corrective actions revealed that they
were in compliance with F600 on June 19, 2025.Interview with the Director of Nursing on July 2, 2025 at
1:00 p.m. revealed staff education was completed, and ongoing audits are to be discussed during the
monthly Quality Assurance (QA) meeting.28 Pa. Code 211.12(d)(1)(5) Nursing services.
Event ID:
Facility ID:
395828
If continuation sheet
Page 6 of 6
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
FAQ · About this visit
Common questions about this visit
What happened during the July 2, 2025 survey of Maple Heights Health & Rehab Center, LLC?
This was a inspection survey of Maple Heights Health & Rehab Center, LLC on July 2, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Maple Heights Health & Rehab Center, LLC on July 2, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.