Health inspection·April 6, 2023

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during wound care for one of four residents reviewed (Resident 1). Residents Affected - Few Findings include: The facility's policy regarding hand washing, dated October 12, 2022, indicated that hands were to be washed before handling clean or soiled dressings, gauze pads, etc. The use of gloves did not replace hand washing/hand hygiene. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 10, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff with daily care activities, had limited range of motion of the upper and lower extremities, had a deep tissue injury (DTI- purple or maroon area of discolored intact skin due to damage of underlying soft tissue) that required treatments, and had diagnoses that included hemiplegia (weakness to one side of the body). Physician's orders, dated March 29, 2023, included an order to clean the area to the resident's right hip with wound cleanser, apply medical grade honey (honey based treatment) to the wound base daily and as needed, and cover with a foam dressing. Physician's orders, dated April 4, 2023, included an order to clean the resident's DTI to the left outer heel with wound cleanser, apply skin prep (protective barrier), and leave open to air. A Certified Registered Nurse Practitioner (CRNP - a registered nurse with advanced training) note, dated April 4, 2023, revealed that Resident 1 had an unstageable pressure ulcer to the right hip that measured 2.0 x 3.0 x 0.2 centimeters (cm) that was previously a DTI. Observations on April 6, 2023, at 2:17 p.m. revealed that Registered Nurse 1 cleaned the wound on the resident's outer left heel with wound cleanser and then applied skin prep, and never washed her hands or performed hand hygiene after cleaning the area to the left outer heel. She then removed the old dressing on the resident's right hip and cleaned the area with wound cleanser, applied medical grade honey to the wound base, and covered the wound with a foam dressing. She did not wash her hands or perform hand hygiene after removing the old dressing to the right hip and cleansing the wound. Interview with Registered Nurse 1 on April 6, 2023, at 2:32 p.m. confirmed that she should have washed her hands after removing Resident 1's old right hip wound dressing and cleansing the wounds, and she did not. (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: 396088 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 396088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Winds Healthcare and Rehabilitation, LLC 4112 Spring Hill Road Portage, PA 15946 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)