Health inspection·January 26, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of transfer for three of three residents reviewed (Residents 1, 2, 3). Findings include: The facility's policy regarding bed holds (holding a resident's bed while the resident is absent from the facility for hospitalization), dated October 6, 2023, indicated that the admission director/designee will contact the resident/resident's representative following a facility-initiated transfer to an acute care facility or hospital. The original copy of the facility's bed-hold policy was to be placed in the resident's chart and the copy can be given to the family. This can be in person or sent via email. If the representative is present, then they can be informed at that time. Then document in the resident's electronic medical record that the resident/representative was notified either via phone call or in person and received a copy and the original was placed in the chart. When making a phone call to the resident/resident representative to inform them of their options, indicate their choice made on the form. Document on the form that the call was made, and the date and time of the call. Nursing notes for Resident 1, dated January 8, 2024, revealed that the resident was admitted to the hospital on this date. However, there was no documented evidence that a written copy of the facility's bed-hold policy was provided to the resident and/or responsible party at the time of his transfer to the hospital. Nursing notes for Resident 2, dated December 30, 2023, revealed that the resident was admitted to the hospital on this date. However, there was no documented evidence that a written copy of the facility's bed-hold policy was provided to the resident and/or responsible party at the time of her transfer to the hospital. Nursing notes for Resident 3, dated August 9, 2023; November 17, 2023; December 3, 2023; and December 16, 2023, revealed that the resident was admitted to the hospital on those dates. However, there was no documented evidence that a written copy of the facility's bed-hold policy was provided to the resident and/or responsible party at the time of his transfers to the hospital. Interview with the Nursing Home Adminstrator on January 26, 2024, at 1:20 p.m. confirmed that a copy of the facility's bed-hold policy was not provided to Residents 1, 2 and 3 or their responsible parties at the time of their transfers to the hospital. (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 5 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 01/26/2024 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)