Health inspection·June 1, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for one of 22 residents reviewed (Resident 12). Residents Affected - Few Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section N0300 (Injections) was to be coded if the resident received an injection in the last seven days or since admission/entry or reentry if less than seven days, and that Section

N0350 (Insulin) was to be coded for the number of days the resident received insulin (an injected medication to lower blood sugar levels), that Sections N0410A (Antipsychotic Medication) and N0410C (Antidepressant Medication) were to be coded with the number of days the resident received these types of medications during the seven-day assessment period, and Section N0450A was to be coded (1) Yes if the resident received an antipsychotic medication since admission/entry or reentry, or since the prior MDS assessment, whichever was more recent. Physician's orders for Resident 12, dated September 30, 2021, included an order for the resident to receive 34 units of Lantus (insulin) at bedtime, two 400 milligram (mg) tablets of Seroquel (an antipsychotic medication) at bedtime for schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), one 16 mg tablet of Perphenazine (an antipsychotic medication) at bedtime for mood disorder, and one 75 mg tablet of Sertraline (an antidepressant) twice a day for depression. Review of Resident 12's Medication Administration Record (MARs), dated March 2023, revealed that the resident received injections of Insulin, the antipsychotic medications of Seroquel and Perphenazine, and the antidepressant medication of Sertraline March 1 through 31, 2023, as ordered by the physician. However, a quarterly MDS assessment, dated March 10, 2023, revealed that Section N0300 was coded with a 0 (zero) indicating that the resident did not receive any injections, Section N0350 was coded with a 0 (zero) indicating that the resident did not receive any Insulin, Sections N0410A and N0410C were coded with a 0 (zero) indicating that the resident did not receive an antipsychotic and an antidepressant, and Section N0450A was coded as 0 (zero) No, indicating that the resident did not receive antipsychotic medication since admission/entry or re-entry, or since the prior MDS assessment. Interview with the Director of Nursing on June 1, 2023, at 1:40 p.m. confirmed that Sections N0300, N0350, N0410A, N0410C, and N0450A of Resident 12's quarterly MDS assessment for March 10, 2023, were coded inaccurately. 28 Pa. Code 211.5(f) Clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 2 of 14 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 06/01/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of four of 22 residents reviewed (Residents 2, 11, 13, 29). Findings include: The facility's policy regarding comprehensive care plans, dated October 12, 2023, indicated that each resident would have an individualized interdisciplinary plan of care in place. The comprehensive care plan would be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission, and as needed or requested by the resident/representative. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 16, 2023, revealed that the resident received an anticoagulant medication (a medication that thins the blood to prevent clots) and a diuretic medication (a medication used to remove excess fluid from the body). Current physician's orders for Resident 2, included orders for the resident to receive 20 milligrams (mg) of Xarelto (an anticoagulant medication) every evening related to atrial fibrillation (irregular heart beat) and 20 mg Furosemide every morning for heart failure. The resident's Medication Administration Records (MAR's) for April and May 2023 revealed that the resident received Xarelto and Furosemide. There was no documented evidence that a care plan was developed related to the use of anti-coagulant and diuretic medications. A nursing note for Resident 2, dated January 6, 2023, at 4:44 p.m. revealed that she spilled hot tea on her left leg. A nursing note, dated May 19, 2023, at 12:00 p.m. revealed Resident 2 spilled hot tea on herself and had a light pinkish area on the upper left front thigh near her groin. There was no documented evidence that a care plan was developed related to the resident spilling hot tea on herself. Interview with the Director of Nursing on June 1, 2023, at 12:23 p.m. confirmed that there were no care plans in place to address Resident 2's use of anti-coagulant and diuretic medications or spilling hot tea on herself. A quarterly MDS assessment for Resident 11, dated May 12, 2023 revealed that the resident received a diuretic medication. Physician's orders for Resident 11, dated February 2, 2023, included an order for the resident to receive 40 mg Furosemide every morning for heart failure. The resident's MAR's for April and May 2023 revealed that the resident received Furosemide. There was no documented evidence that a care plan was developed related to the use of diuretic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 3 of 14 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 06/01/2023 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)

F 0656 medications. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on June 1, 2023, at 12:23 p.m. confirmed that there was no care plan in place to address Resident 11's use of diuretic medications. Residents Affected - Some A urine culture for Resident 13, dated May 15, 2022, indicated that the resident had extended-spectrum beta-lactamase (ESBL-occurs when bacteria break down antibiotics, thereby making infections very hard to treat) of the urine. Physician's orders for Resident 13, dated May 22, 2023, included orders for contact precautions due to ESBL of the urine. There was no documented evidence that a care plan was developed related to Resident 13's isolation precautions. Interview with the Director of Nursing on May 31, 2023, at 3:41 p.m. confirmed that there was no care plan developed to address Resident 13's isolation precautions. An admission MDS assessment for Resident 29, dated May 4, 2023, revealed that the resident received an anticoagulant and antibiotic medications, and used oxygen, Current physician's orders for Resident 29, included orders for the resident to receive 5 mg of Eliquis (an anticoagulant medication) every morning and at bedtime related to atrial fibrillation, 875-125 mg of Amoxicillin- Potassium Clavulanate (antibiotic) every morning and at bedtime related to infection and inflammatory reaction due to cardiac or vascular devices, and 1-5 liters per minute of oxygen via nasal cannula for shortness of breath. The resident's MAR's for April and May 2023 revealed that the resident received Eliquis, Amoxicillin-Potassium Clavulanate, and oxygen. There was no documented evidence that a care plan was developed related to the use of anti-coagulant and antibiotic medications or oxygen use. Interview with the Director of Nursing on June 1, 2023, at 12:16 p.m. confirmed that there were no care plans developed to address Resident 29's use of Eliquis, Amoxicillin-Potassium Clavulanate, or oxygen. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 4 of 14 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 06/01/2023 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)

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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about elevated blood sugar results for one of 22 residents reviewed (Resident 16). Residents Affected - Some Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated April 2, 2023, revealed that the resident was understood, understands, required extensive assistance for her daily care needs, had a diagnosis which included diabetes (disease that interferes with blood sugar control), and received insulin (medication that lowers blood sugar levels). A care plan for the resident, dated May 12, 2022, revealed that the resident has diabetes and staff was to obtain accuchecks (a fingerstick blood sugar test) as ordered. Physician's orders for Resident 16, dated September 30, 2021, included an order for the resident to receive Lispro (Insulin) according to a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) before meals for diabetes. The sliding scale included giving 2 units for a blood sugar of 141-180 milligrams/deciliter (mg/dL); 4 units of insulin for a blood sugar of 181-220 mg/dL; 6 units of insulin for a blood sugar of 221-260 mg/dL; 8 units of insulin for a blood sugar of 261-300 mg/dL; 10 units for a blood sugar of 301-340 mg/dL; and 12 units for a blood sugar of 341 or greater and call the physician. Resident 16's Medication Administration Record (MAR) for March, April, and May 2023 revealed that on March 11, 2023, at 11:45 a.m. the resident's blood sugar was 347 mg/dL; on March 18, 2023, at 11:45 a.m. it was 388 mg/dL; on April 13, 2023, at 7:15 a.m. it was 342 mg/dL; on April 13, 2023, at 4:40 p.m. it was 387 mg/dL; on May 6, 2023, at 7:15 a.m. it was 379 mg/dL; on May 15, 2023, at 4:40 p.m. it was 358 mg/dL; and on May 30, 2023, at 7:15 a.m. it was 379 mg/dL. There was no documented evidence that the physician was notified about the resident's blood sugar being above 341 mg/dL on these dates and times. Interview with the Director of Nursing on May 31, 2023, at 2:35 p.m. confirmed that there was no documented evidence that the physician was notified about Resident 16's elevated blood sugars, as ordered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 5 of 14 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 06/01/2023 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. 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's orders for enteral feedings (feeding through a tube inserted directly into the stomach) were followed and clarified for one of 22 residents reviewed (Resident 9). Findings include: The facility's policy regarding guidelines for enteral feedings, dated October 12, 2022, indicated that staff are to ensure that the enteral feeding is provided as ordered. That nursing staff will check gastric residual (the amount of liquid that remains in the stomach following administration of enteral feed) every shift or more frequently as indicated. Residuals of 50 milliliters (ml) or more suggests that the feeding should be held for at least one hour. A care plan for Resident 9, dated January 2, 2021, revealed that the resident required an enteral feeding related to Dysphagia (swallowing difficulties), nothing by mouth (NPO), and weight fluctuations. Staff was to check for tube placement and gastric contents/residual volume per facility protocol/procedure and hold the feeding as per physician's orders. Physician's orders for Resident 9, dated April 14, 2023, included an order for the resident to receive 400 ml of Osmolite 1 Cal (a type of enteral feeding) four times a day. If the enteral feeding residual was greater than 200 ml, staff was to hold the enteral feeding and call the physician. Physician's orders for Resident 9, dated May 22, 2023, included an order for the resident to receive 400 ml of Osmolite 1.2 Cal four times a day. If the enteral feeding residual was greater than 200 ml, staff was to hold the enteral feeding and call the physician. Medication Administration Records (MARs) for Resident 9, dated April and May 2023 revealed that staff administered the 400 ml of Osmolite 1 Cal on April 14, 2023, at 5:00 p.m. and 9:00 p.m.; on April 15 through April 30, 2023; May 1 through 4, 2023, at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m.; and on May 5, 2023 at 9:00 a.m. However, there was no documented evidence that staff obtained and/or documented the amount of any tube feeding residual. Review of the MARs for Resident 9 for May 2023 revealed that staff administered the 400 ml of Osmolite 1.2 Cal on May 22, 2023, at 5:00 p.m. and 9:00 p.m.; May 23, 2023, at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m.; and on May 24, 2023, at 9:00 a.m. However, there was no documented evidence that staff obtained and/or documented the amount of any tube feeding residual. Physician's orders for Resident 9, dated May 22, 2023, included an order for the resident to receive 400 ml Osmolite 1.0 Cal four times a day until the Osmolite 1.2 Cal arrives. However, there was no documented evidence that staff clarified with the resident's physician if the enteral feeding residuals should be checked and if the enteral feeding residual was greater than 200 ml to hold the enteral feeding and call the physician. Review of the MARs for Resident 9 for May 2023 revealed that staff administered the 400 ml of Osmolite 1.0 Cal on May 24, 2023, at 1:00 p.m., 5:00 p.m. and 9:00 p.m. and May 25 through 31, 2023, at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. However, there was no documented evidence that staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 6 of 14 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 06/01/2023 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)

F 0693 obtained and/or documented the amount of any tube feeding residual per the facility's policy. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on June 1, 2023, at 12:16 p.m. confirmed that there was no documented evidence that staff obtained Resident 9's tube feeding residuals and no documented evidence that staff clarified with the resident's physician if the enteral feeding residuals should be checked and if the enteral feeding residual was greater than 200 ml to hold the enteral feeding and call the physician. Residents Affected - Some 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 7 of 14 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 06/01/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 22 residents reviewed (Residents 2, 17). Findings include: The facility's policy regarding documentation of medication administration, dated October 12, 2022, indicated that each resident would have an individualized interdisciplinary plan of care in place. The comprehensive care plan was to be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission, and as needed or requested by the resident/representative. The comprehensive care plan was to be resident centered and on-going, focusing on each individual resident as a unitary being. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 16, 2023, revealed that the resident could make herself understood and understand others, was alert and oriented, had frequent pain, received pain medication routinely and as needed, and received an opioid (a controlled pain medication). Physician's orders, dated September 1, 2022, included an order for the resident to receive 5 milligrams (mg) of Oxycodone (a narcotic pain medication) every eight hours as needed for moderate/severe pain and physician's orders, dated May 10, 2023, included an order for the resident to receive 5 mg of Oxycodone every four hours as needed for moderate/severe pain. A controlled drug accountability record (tracks each dose of a controlled medication) for Resident 2's Oxycodone revealed that one tablet was signed out on the controlled drug log at 6:00 p.m. on April 6; at 9:30 p.m. on April 22; at 9:40 a.m. on April 29; at 12:45 p.m. on April 30; at 4:40 p.m. on May 14; and at 11:00 a.m. on May 20, 2023. There was no documented evidence, including on the MAR, that the signed-out doses of Oxycodone were administered to Resident 2 on these dates and times. Interview with the Director of Nursing on June 1, 2023, at 9:42 p.m. confirmed that the 5 mg doses of Oxycodone that were signed out on Resident 2's controlled medication log on the mentioned dates and times were not documented on the MAR as being administered. Physician's orders for Resident 17, dated March 23, 2023, included an order for the resident to receive 0.5 milliliter (ml) of a 20 mg/ml solution of Morphine (a narcotic pain medication) every one hour as needed for pain/shortness of breath. Resident 17's controlled substance proof-of-use record for April 2023 revealed that licensed staff signed out 0.5 ml dose of Morphine for administration to the resident on April 23, 2023, at 8:00 p.m. However, there was no documented evidence in the resident's clinical record, including on the MAR and nursing notes, that the Morphine was actually administered to the resident on April 23, 2023, at 8:00 p.m. Physician's orders for Resident 17, dated April 26, 2023, included an order for the resident to receive one 1 mg tablet of Lorazepam (a narcotic antianxiety medication) every two hours as needed for anxiety/restlessness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 8 of 14 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 06/01/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 17's controlled substance proof-of-use record for April 2023 revealed that licensed staff signed out 1 mg dose of Lorazepam for administration to the resident on April 27, 2023, at 9:40 p.m. However, there was no documented evidence in the resident's clinical record, including on the MAR and nursing notes, that the Lorazepam was actually administered to the resident on April 27, 2023, at 9:40 p.m. Interview with the Director of Nursing on June 1, 2023, at 9:42 a.m. revealed that she could not locate any documentation regarding why the Morphine and Lorazepam were signed out but not administered to Resident 17, or any documentation that the Morphine and Lorazepam were administered after being signed out on the above dates and times. 28 Pa. Code 211.9(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 9 of 14 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 06/01/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to store food in a sanitary manner. Residents Affected - Some Findings include: A review of the facility's policy regarding Cleaning and Disinfecting of Refrigerators, dated October 12, 2022, revealed that the refrigerators are to be cleaned on a weekly basis and as needed. Observations in the pantry refrigerator on May 30, 2023, at 12:26 p.m and May 31, 2023, at 2:07 p.m. revealed that there was a large spill of a brown, sticky, removable substance down the back of the refrigerator wall and accumulated under the bottom drawer. Interview with the the Dietary Manager on May 31, 2023, at 2:11 p.m. confirmed that the spill should have been cleaned up when the refrigerator was re-stocked earlier that day and it was not. 28 Pa. Code 211.6(f) Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 10 of 14 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 06/01/2023 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of 22 residents reviewed (Resident 7). Residents Affected - Few Findings include: Physican orders for Resident 7, dated February 3, 2023, included an order for the resident to be administered oxygen at 1 to 5 liters per minute (lpm) via nasal canula for shortness of breath/comfort. Observations of Resident 7 on May 30, 2023, at 10:06 a.m. and 3:10 p.m. and on May 31, 2023, at 9:51 a.m., 12:53 p.m., and 3:04 p.m. revealed that the oxygen was being administered at 5 lpm. However, Resident 7's treatment record revealed that on May 30 and 31, 2023 the oxygen was documented as being administered at 2 lpm. Interview with Registered Nurse 1 on May 31, 2023, at 3:04 p.m. confirmed that on May 30 and 31 the oxygen was being administered to Resident 7 at 5 lpm; however, it was documented as 2 lpm. Interview with the Director of Nursing on May 31, 2023, at 3:37 p.m. confirmed that staff should not have documented Resident 7's oxygen administration at 2 lpm if it was being administered at 5 lpm. 28 Pa. Code 211.5(f) Clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 11 of 14 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 06/01/2023 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)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and/or maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the surveys ending May 11, 2022, and April 6, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending June 1, 2023, identified repeated deficiencies related to inaccurate Minimum Data Sets (MDS), care plan development and implementation, feeding tube management, pharmacy services, food procurement/storage/preparation/service, and infection control. The facility's plans of correction for deficiencies regarding inaccurate MDS, cited during the survey ending May 11, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding careplan creation and implementation, cited during the survey ending May 11, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding feeding tube management, cited during the survey ending May 11, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F693, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding pharmacy services, cited during the survey ending May 11, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding food procurement/storage/preperation/serving, cited during the survey ending May 11, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding infection control, cited during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 12 of 14 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 06/01/2023 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)

F 0867 Level of Harm - Minimal harm or potential for actual harm surveys ending May 11, 2022 and April 6, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F880, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. Residents Affected - Few Refer to F641, F656, F693, F755, F812, F880. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 13 of 14 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 06/01/2023 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)

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 appropriate signage was posted for a resident with special infection control isolation needs for one of 22 residents reviewed (Resident 13) and failed to ensure that proper infection control practices were followed during medication administration for one of 22 residents reviewed (Resident 7) Residents Affected - Few Findings include: A review of the facility's policy regarding Medication Administration, dated October 12, 2022, revealed that staff follow established facility infection control procedures for the administration of medications. Current physician's orders for Resident 7 included orders for the resident to receive 20 milligrams (mg) Celexa (anti-depressant) and 25 mg Spironolactone (blood pressure medication). Observations during medication administration on May 31, 2023, at 8:57 a.m. revealed that Registered Nurse 1 dropped the Celexa on the medication cart and picked it up with her bare hands and then placed it in the medication cup. She then dropped the Spironolactone on the medication cart and picked it up with her bare hands. She then administered the medications to Resident 7. Interview with Registered Nurse 1 on May 31, 2023, at 9:14 a.m. revealed that she should not have touched Resident 7's medication with her bare hands. Interview with the Director of Nursing on May 31, 2023, at 3:47 p.m. confirmed that staff were not to touch residents' medications with their bare hands. The facility's policy regarding isolation precautions, dated October 12, 2022, indicated that when a resident was placed on transmission-based precautions, appropriate notification was placed on the room entrance door so that personnel and visitors were aware of the need for and the type of precaution. A urine culture, dated May 15, 2022, indicated that Resident 13 had extended-spectrum beta-lactamase (ESBL-occurs when bacteria break down antibiotics, thereby making infections very hard to treat) of the urine. Physician's orders for Resident 13, dated May 22, 2023, included orders for contact precautions due to ESBL of the urine. Observation on May 30, 2023, at 10:14 a.m. and 10:36 a.m. revealed that there was no infection control sign posted at the entrance to the resident's room. Interview with the Director of Nursing on May 31, 2023, at 3:41 p.m. confirmed that there should have been an infection control sign by Resident 13's room door. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 14 of 14