Inspection·June 5, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to address and maintain advance directives as part of the clinical record for one of 27 residents reviewed (Resident 29). Findings include: The facility's policy regarding advance directives (instructions regarding the provision of health care and life sustaining measures when the resident is incapacitated), dated May 6, 2024, indicated that upon admission residents and/or their responsible party are asked if an advanced directive or living will exists. If an advanced directive or living will exists, it is reviewed and placed in the resident's chart. If an advanced directive or living does not exist, the resident and/or their responsible party are asked if they wish to complete one. Advanced directives are reviewed with the residents as needed by social worker and acknowledgment forms are filed in the resident's medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated April 25, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, and had diagnoses that included cerebral infarction (lack of blood supply to the brain resulting in brain death to parts of the brain) and depression (a mood disorder). There was no documented evidence that advance directives were addressed with Resident 29 and maintained as part of her clinical record. Interview with the Director of Nursing on June 5, 2024, at 1:00 p.m. confirmed the there was no documented evidence that advance directives were addressed with Resident 29 and maintained as part of her clinical record. 28 Pa. Code 201.29(a)(d) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 2 of 21 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 06/05/2024 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)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for one of two nurses reviewed (Licensed Practical Nurse 2) and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 3). Residents Affected - Few Findings include: The facility's policy regarding abuse, neglect or mistreatment, dated May 6, 2024, indicated that potential employees must pass the pre-employment screening process to be hired at the facility. Potential employees must pass a criminal background check inquiring for a history of abuse, neglect, or mistreatment of residents as defined by the requirements of federal regulations. This search includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. The personnel file for Licensed Practical Nurse 2 revealed a start date of February 10, 2019. However, there was no documented evidence until July 12, 2019, that her license was verified with the state board prior to her working. The personnel file for Nurse Aide 3 revealed a start date of March 26, 2024. However, there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified. Interview with the Human Resources Director on June 5, 2024, at 10:40 a.m. confirmed that Licensed Practical Nures 2's start date was February 10, 2019, and her license was not verified with the State Board of Nursing until July 12, 2019. She also confirmed that Nurse Aide 3 had a start date of March 26, 2024, and did not have a registry verification completed prior to her start date. 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 3 of 21 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 06/05/2024 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 27 residents reviewed (Residents 13, 29, 43). Findings include: A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024 revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, required assistance from staff for personal care needs, and had a mechanically altered therapeutic diet. A care plan for Resident 13, dated June 21, 2022, revealed that she had an impaired nutritional status and required a mechanically altered therapeutic diet with thickened liquids that was to be provided as ordered. Physician's orders for Resident 13, dated May 9, 2024, included orders for the resident tor receive a carbohydrate controlled, mechanically soft textured diet, with thin consistency liquids, and may have salads per speech therapy. A nutrition note for Resident 13, dated May 15, 2024, indicated that the previous diet of mechanical soft with nectar thick liquids was changed to thin liquids on May 9, 2024. Interview with The Director of Nursing on June 5, 2024, at 1:45 p.m. confirmed that Resident 13's care plan should have been revised to reflect the current diet orders of May 9, 2024. A quarterly MDS assessment for Resident 29, dated April 25, 2024, revealed that the resident was understood and could understand others, required assistance with care needs, had a Foley catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), and had a diagnosis of neuromuscular dysfunction of the bladder (bladder lacks control due to nerve or muscle problems). A physician's order for Resident 29, dated March 22, 2024, indicated that the resident was ordered an 18 French (size of catheter), 5-15 milliliter (ml) balloon (size of balloon used to secure in place once inserted) Foley catheter. A care plan for Resident 29, dated January 16, 2024, indicated that the resident had a 16 French, 10 ml balloon Foley catheter. Observations of Resident 29 on June 5, 2024, at 2:22 p.m. revealed that the resident had an 18 French, 5-15 ml balloon foley catheter in place. Interview with The Director of Nursing on June 5, 2024, at 3:55 p.m. revealed that Resident 29's care plan should have been revised to reflect the correct size of Foley catheter ordered and it was not. A baseline care plan for Resident 43, dated May 15, 2024, revealed that the resident was receiving antibiotics through a Peripherally Inserted Central Catheter or PICC line (type of long tube that is inserted through a vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period). Physician's orders for Resident 43, dated May 17, 2024, included an order that the PICC line was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 4 of 21 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 06/05/2024 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)

F 0657 discontinued and able to be removed. Level of Harm - Minimal harm or potential for actual harm Observations of Resident 43 on June 3, 2024, at 12:22 p.m. revealed that the resident no longer had a PICC line in place and was no longer receiving antibiotics. Residents Affected - Few Interview with Resident 43 on June 3, 2024, at 12:25 p.m. revealed that the resident stopped receiving antibiotics and had the PICC line removed two days after being admitted to the nursing facility, Interview with The Director of Nursing on June 4, 2024, at 3:39 p.m. revealed that Resident 43's care plan should have been revised to reflect that the resident was no longer receiving antibiotics and had the PICC line removed. 28 Pa. Code 201.24(e)(4) admission Policy. 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 5 of 21 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 06/05/2024 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of Pennsylvania's Nursing Practice Act, clinical records, and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a fall for one of 27 residents reviewed (Resident 13). Residents Affected - Few Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024, revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance from staff for personal care needs. A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that the resident was out of bed on the floor between her bed and the wall. Upon entering her room, she was lying on her left side, legs extended in front of her, and her hands reaching in the air. A fall investigation, dated February 17, 2024, at 9:00 p.m., revealed that a comment was added to the note section of the investigation by a registered nurse stating, Resident was assessed status post fall and agree with the assessment done by the nurse on duty. The fall investigation was privileged and confidential and was not part of the medical record. There was no documented evidence in the clinical record that Resident 13 was assessed by a registered nurse following her fall on February 17, 2024. Interview with the Director of Nursing on June 4, 2024, at 12:58 p.m. confirmed that there was no documented evidence in the clinical record of a registered nurse assessment at the time of Resident 13's fall on February 17, 2024. 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 6 of 21 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 06/05/2024 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)

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's orders for were followed for three of 27 residents reviewed (Residents 11, 27, 35) and failed to ensure that neurological checks were completed following an unwitnessed fall for one of 27 residents reviewed (Resident 13). Residents Affected - Some Findings include: A facility policy related to physician's orders, dated May 6, 2024, indicated that medications, treatments, and care is provided to residents upon written and/or verbal order. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, received insulin, and had diagnoses that included diabetes. Physician's orders for Resident 11, dated October 18, 2023, included an order for the resident to receive 44 units of Glargine insulin (a long-acting insulin) subcutaneously (injected just under the skin) daily at bedtime and hold if blood sugar is less than 150 milligrams per deciliter (mg/dl). A review of Resident 11's Medication Administration Record (MAR) for April 2024 revealed that the resident's bedtime blood sugar was 118 mg/dl on April 17, 2024; 148 mg/dl on April 24, 2024; 146 mg/dl on April 26, 2024; and 123 mg/dl on April 30, 2024. Glargine insulin was documented on the MAR as having been administered on the above stated dates. Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that Glargine insulin was administered to Resident 11 on the above stated dates and should not have been. A facility policy related to falls, dated May 6, 2024, revealed that resident falls were reported, their causes identified when possible, and timely interventions were established to help reduce the probability of repeated incidents. A quarterly MDS assessment for Resident 13, dated May 14, 2024 revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance from staff for personal care needs. A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that she was found lying on her fall mats on her back with her legs extended in front of her. A review of Resident 13's medical chart revealed no documented evidence that neurological checks were completed for the unwitnessed fall on February 21, 2024. Interview with the Director of Nursing on June 5, 2024, at 9:19 a.m. confirmed that neurological checks should be completed after unwitnessed falls, and was unable to find them for Resident 13 for the fall occurring on February 21, 2024. An admission MDS assessment for Resident 27, dated May 15, 2024, revealed that the resident was cognitively impaired and required extensive assistance for daily care needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 7 of 21 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 06/05/2024 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Physician's orders for Resident 27, dated May 24, 2024, included an order for the resident to have a treatment for a skin tear on her left forearm. A review of Resident 27's Treatment Administration Record (TAR) for May 2024 revealed no documented evidence that the treatment for the skin tear on Resident 27's left forearm was completed as ordered by the physician. Interview with the Director of Nursing on June 4, 2024, at 11:30 a.m. confirmed that treatments for the skin tear on Resident 27's left forearm were not completed as ordered. A quarterly MDS assessment for Resident 35, dated March 8, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, and had one fall with injury. A nurse's note for Resident 35, dated May 14, 2024, revealed that the resident had an unwitnessed fall at bedside, the resident was assessed, and neurological checks (a neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired) were to be completed. A review of Resident 35's medical chart revealed no documented evidence neuro checks were completed for the unwitnessed fall on May 14, 2024. Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that neuro checks should be completed after unwitnessed falls. A facility policy for Bowel Protocol, dated May 6, 2024, revealed that a resident should have a soft, formed bowel movement every third day or sooner. Physician's orders for Resident 35, dated November 30, 2023, included an order for the resident to receive a 5 mg tablet of Dulcolax (a laxative that stimulates bowel movements) by mouth as needed for constipation on Day 3 with no bowel movement and a Dulcolax suppository 10 mg rectally as needed for constipation on Day 4 with no bowel movement. Nurse's note for Resident 35, dated April 10, 2024, revealed the resident's last bowel movement was April 4, 2024, and there was no documented evidence that bowel protocol was administered. Interview with Director of Nursing on June 5, 2024, at 12:53 p.m. revealed that the bowel protocol was not initiated for Resident 35 on Day 3 and Day 4 with no bowel movement and should have been. 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 8 of 21 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 06/05/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow treatment recommendations for one of six residents reviewed (Resident 6). Residents Affected - Few Findings include: A facility policy regarding pressure ulcer prevention and management, dated May 6, 2024, revealed that a wound care nurse consult would include assessment and finding, which may include stage, measurements, appearance, and treatment recommendations in the consult report. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 27, 2024, indicated that the resident was usually understood and could usually understand others, was dependent on staff for care, and was at risk for a pressure ulcer (skin breakdown caused by prolonged, unrelieved pressure). Physician's orders for Resident 6, dated May 15, 2024, included an order for the resident to have his right heel cleansed, patted dry, Medihoney (wound ointment) applied, then covered with bordered gauze once daily and as needed for a pressure wound. A skin and wound note for Resident 6, dated May 30, 2024, at 1:05 p.m. revealed that the resident was seen by the wound consultant, who recommended to change the frequency of the right heel dressing to twice a day and as needed. As of June 5, 2024, there was no documented evidence that Resident 6's wound care was completed twice a day as recommended by the wound consultant. Interview with the Director of Nursing on June 5, 2024, at 3:06 p.m. and 3:32 p.m. confirmed that the Registered Nurse Supervisor who completed rounds with the wound consultant did not update the order, and the treatment was not completed twice daily as recommended by the wound consultant and should have been. 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 9 of 21 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 06/05/2024 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that contracture management services were provided as care planned for one of 27 residents reviewed (Resident 25). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 20, 2024, revealed that the resident was able to make herself understood and was able to understand others, was dependent on staff for her daily care needs, and had diagnoses that included hemiplegia (muscle weakness or partial paralysis on one side of the body). Occupational Therapy orders for Resident 25, dated January 10, 2024, included an order for the resident to have passive range of motion (when someone physically moves or stretches a part of your body) to all joints in her left hand twice a day. A care plan for Resident 25, dated May 1, 2024, revealed that the resident was on a restorative nursing program for range of motion. Nursing tasks for Resident 25 included that the resident was to have passive range of motion to all joints in her left hand scheduled twice a day. Documentation for this task revealed that the resident only received passive range of motion one time per day on May 8, 9, 10, 11, 12, 18, 19, 20, 28, 30, and June, 1, 2024. An interview with Occupational Therapist 4 on June 4, 2024, at 2:59 p.m. revealed that passive range of motion programs for restorative nursing is recommended by therapy. The recommendations are then reviewed by the Director of Nursing, scheduled to be completed twice a day by nursing staff, and added to the care plan by the Licensed Practical Nurse Assessment Coordinator. Recommendations for Resident 25 included passive range of motion twice a day. Interview with the Director of Nursing on June 6, 2024, at 10:18 a.m. confirmed that there was no documented evidence to confirm that Resident 25 received passive range of motion twice a day per the recommendations and should have. 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 10 of 21 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 06/05/2024 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)

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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for four of 27 residents reviewed (Residents 2, 11, 29, 34). Findings include: The facility's policy regarding medication administration, dated May 6, 2024, revealed that all medications were ordered, acquired, and administered in accordance with Pennsylvania State Regulations as governed by the Centers of Medicare and Medicaid Services, and in accordance with all policies and procedures of the facility. If a medication was to be administered at a specific time, the specific time may be based upon resident's choice. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 7, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated as a 5 out of 10 on a pain scale, and was receiving controlled pain medication. A care plan, dated November 1, 2023, revealed that Resident 2 had pain related to rhabdomyolysis (muscle injury where muscles break down). Physician's orders for Resident 2, dated February 29, 2024, included an order for the resident to receive 5 milligrams (mg) of Oxycodone (an opioid pain medication) immediate release every eight hours as needed for moderate to severe pain for a pain scale rating of 6 to 10 for 14 days. Physician's orders for Resident 2, dated March 15, 2024, included an order for the resident to receive 5 mg of Oxycodone immediate release every eight hours as needed for pain. Physician's orders for Resident 2, dated March 29, 2024, included an order for the resident to receive 5 mg of Oxycodone immediate release every six hours as needed for chronic pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 2 for March 2024 through June 2024 indicated that a dose of Oxycodone was signed out on March 3, 2024, at 10:19 a.m.; March 28, 2024, at 3:35 p.m.; April 1, 2024, at 6:30 a.m.; April 15, 2024, at 6:30 a.m.; April 29, 2024, at 6:30 a.m.; May 1, 2024, at 6:30 a.m.; May 9, 2024, at 6:30 a.m.; May 29, 2024, at 6:30 a.m.; and June 2, 2024, at 6:30 a.m. However, a review of Resident 2's MAR and nursing notes revealed no documented evidence that the signed-out doses of Oxycodone were administered to the resident on the above stated dates and times. Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that there was no documented evidence in Resident 2's clinical records to indicate that the signed-out doses of Oxycodone were administered to the resident on the above stated dates and times. A quarterly MDS assessment for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated a 7 out of 10 on a pain scale, and was receiving controlled pain medication. Current physician's orders for Resident 11 included an order for the resident to receive 5-325 milligrams (mg) of Hydrocodone-acetaminophen (an opioid pain medication) every four hours as needed for a pain scale of 4 to 10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 11 of 21 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 06/05/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the controlled drug record for Resident 11 for March and May 2024 indicated that a dose of Hydrocodone-acetaminophen was signed out on March 8, 2024, at 1:00 a.m. and on May 14, 2024, at 9:40 a.m. However, a review of Resident 11's MAR and nursing notes revealed no documented evidence that the signed-out doses of Hydrocodone-acetaminophen were administered to the resident on the above stated dates and times. Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that there was no documented evidence in Resident 11's clinical records to indicate that the signed-out doses of Hydrocodone-acetaminophen were administered to the resident on the above stated dates and times. A quarterly MDS assessment for Resident 29, dated April 25, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated a 7 out of 10 on a pain scale, and was receiving controlled pain medication. Physician's orders for Resident 29, dated January 21, 2024, included an order for the resident to receive 50 mg of Tramadol (an opioid pain medication) every eight hours as needed for moderate to severe pain. Review of the controlled drug record for Resident 29 for March and June 2024 indicated that a dose of Tramadol was signed out on March 17, 2024, at 11:27 a.m. and on June 3, 2024, at 12:05 a.m. However, a review of Resident 29's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times. Interview with the Director of Nursing on June 5, 2024, at 3:55 p.m. confirmed that there was no documented evidence in Resident 29's clinical records to indicate that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times. A quarterly MDS assessment for Resident 34, dated February 5, 2024, revealed that the resident was understood and could understand others, was cognitively impaired, had complaints of pain rated as an 8 out of 10 on a pain scale, and was receiving controlled pain medication. Physician's order for Resident 34, dated February 28, 2024, included an order for the resident to receive 50 milligrams (mg) of Tramadol every six hours as needed for moderate to severe pain for a pain scale rating of 4 to 10. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 34 for March 2024 through June 2024 indicated that a dose of Tramadol was signed out on March 4, 2024, at 7:30 p.m.; March 15, 2024, at 9:00 p.m.; March 17, 2024, at 9:00 p.m.; and May 28 ,2024, at 9:00 p.m. Review of Resident 34's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times. Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that there was no documented evidence in Resident 34's clinical records to indicate that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 12 of 21 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 06/05/2024 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)

F 0755 28 Pa. Code 211.9(a)(h) Pharmacy Services. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing Services. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 13 of 21 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 06/05/2024 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to pharmacy recommendations for four of 27 residents reviewed (Residents 3, 11, 35, 36) and failed to obtain completed pharmacy recommendations for physician review for two of 27 residents reviewed (Residents 10, 29). Findings include: The facility's policy for drug regimen review, dated May 6, 2024, indicated that a drug regimen review is performed by a licensed pharmacist for every resident each month. The pharmacist will report any medication irregularities and recommendations to the attending physician on a pharmacy review sheet. The physician will respond to the pharmacist's recommendation on the review sheet, and it will be returned to the facility to be acted upon. The review sheet will be filed in the resident's chart in the physician progress section and will be kept in the chart for one full year. A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 3, dated April 12, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, received insulin (a medication preperation of the hormone insulin), and had a diagnosis of diabetes (disease causing high blood sugar levels). A pharmacy review sheet for Resident 3, dated March 5, 2024, included a recommendation that a correction needed to be made to Resident 3's orders due a change in insulin dose at bedtime. There was no documented evidence that the pharmacy recommendation was addressed timely by the physician. Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendation for Resident 3 on March 5, 2024, was not addressed timely by the physician. A quarterly MDS assessment for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, received insulin and controlled pain medication, and had diagnoses that included diabetes. Review of a pharmacy review sheet for Resident 11, dated March 5, 2024, revealed a recommendation that the resident may be due for blood work related to drug therapy. However, there was no documented evidence that the pharmacy recommendations were addressed timely by the physician. Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 11 on March 5, 2024, were not addressed timely by the physician and should have been. A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 35, dated March 8, 2024, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs, and received an antianxiety medication (a drug used to treat anxiety) and an antidepressant medication (a drug used to treat depression). Progress notes for Resident 35, dated March 5, 2024; April 12, 2024; and May 13, 2024, revealed that a pharmacy review was done and recommendations were made. However, there was no documented evidence that the pharmacy recommendations were addressed timely by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 14 of 21 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 06/05/2024 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 35 on March 5, 2024; April 12, 2024; and May 13, 2024, were not addressed timely by the physician and they should have been. An annual MDS assessment for Resident 36, dated May 14, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, and was receiving an antianxiety medication (used to control anxiety) and a medication for insomnia (used to control sleep). Review of a pharmacy recommendation for Resident 36, dated March 5, 2024, revealed a recommendation that it may be appropriate to discontinue one of the medications for anxiety and insomnia and that a correction was made to Resident 3's orders. However, there was no documented evidence that the pharmacy recommendations were addressed timely by the physician. Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 36 on March 5, 2024, were not addressed timely by the physician and they should have been. A significant change MDS assessment for Resident 10, dated May 2, 2024, revealed that the resident was understood and could understand others, was dependent for care needs, received controlled pain medication, and had diagnoses that included atrial fibrillation (irregular heart rhythm). A progress note for Resident 10, dated February 19, 2024, revealed that a pharmacy review was done and that recommendations were made. However, there was no documented evidence that the pharmacy recommendations were received for the physician to review. Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 10 on February 19, 2024, were not obtained for the physician to review and should have been. A quarterly MDS assessment for Resident 29, dated April 25, 2024, revealed that the resident was understood and could understand others and was receiving controlled pain medication, antipsychotic medications (used to treat mental health disorders), antidepressant medications (used to treat depression) and anticoagulant medications (used to treat or prevent blood clots). A progress note for Resident 29, dated March 5, 2024, revealed that a pharmacy review was done and recommendations were made. However, there was no documented evidence that the pharmacy recommendations were obtained for physician review. Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 29 on March 5, 2024, were not obtained for physician review and they should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 15 of 21 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 06/05/2024 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart. Findings include A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 244, dated May 28, 2024 revealed that the resident understood others and was understood, was cognitively intact, required assistance from staff for personal care needs, and has a diagnosis of gout (a build up of uric acid that causes pain and inflammation). Observations on June 3, 2024, at 10:49 a.m. revealed that there was a round white pill on the floor of Resident 244's room. Physician orders for Resident 244, dated May 13, 2024, included an order for the resident to be administered 100 milligrams (mg) of Allopurinol in the morning for gout. Interview with Licensed Practical Nurse 5 on June 3, 2024, at 10:59 a.m. confirmed the white pill with 349 IJ was identified as Allopurinol (a medication used to treat gout), and Resident 244 was currently prescribed the medication. Interview with the Director of Nursing on June 3, 2024, at 2:06 p.m. confirmed that the medication should have been labeled and secured, not on the resident's floor. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 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 16 of 21 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 06/05/2024 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of the facility's written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu. Residents Affected - Many Findings include: A facility's policy regarding menu management, dated May 6, 2024, revealed that menus were to be posted on menu boards located in the dining room and hallway. Temporary changes to the menu will be posted daily on the menu boards. To ensure consistency, all meals served will strictly adhere to the pre-approved menus. The facility's written and posted weekly menu for the lunch meal on June 3, 2024, revealed that the residents were to receive bread with margarine. Observations during the lunch meal on June 3, 2024, at 12:08 p.m. revealed that the residents did not receive bread or margarine for the lunch meal. Interview with the Dietary Manager on June 3, 2024, at 12:58 a.m. revealed that a new cook eliminated the bread from the menu for lunch and she did not know why, but the residents should have been provided bread and margarine with their meal. 28 Pa. Code 211.6(a) Dietary Services. 28 Pa. Code 201.29(j) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 17 of 21 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 06/05/2024 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 27 residents reviewed (Resident 13). Findings include: The facility's policy regarding nursing documentation, dated May 6, 2024, revealed that all documentation confirms that care was provided. Documentation identifies the resident's status, clinical findings and interventions. It is the staff's responsibility in documentation, which acts as proof that care was provided. All documentation was to be done in the electronic record Point Click Care (PCC). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024, revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance staff for personal care needs. A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that she was lying on her fall mats on her back, with legs extended in front of her. A fall investigation, dated February 21, 2024, at 6:45 p.m., revealed that Resident 13 was found sitting on the floor in her room with her alarm sounding. The investigation was privileged and confidential, and not part of the clinical record. The notes section of the investigation revealed that the registered nurse was present during the fall assessment and the resident was able to tolerate passive range of motion to the bilateral lower extremity. The bilateral lower extremities were equal in length, and no internal or external rotation was noted. There was no documented evidence that a registered nurse assessment was documented in the clinical record. Interview with the Director of Nursing on June 4, 2024, at 12:58 p.m. confirmed that the resident was assessed by a registered nurse and confirmed that there was no documentation of the assessment in the clinical record. 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 18 of 21 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 06/05/2024 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)

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 and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct 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) survey ending June 1, 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 5, 2024, identified repeated deficiencies related to failure to develop resident care plans, failure to provide quality of care, failure to maintain complete and accurate medical records, and failure to maintain a complete and accurate accounting of controlled medications. The facility's plans of correction for deficiencies regarding developing and implementing comprehensive care plans, cited during the survey ending June 1, 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 F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding developing and implementing comprehensive care plans. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending June 1, 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 F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care. The facility's plan of correction for a deficiency regarding failure to maintain a complete and accurate accounting of controlled medications, cited during the survey ending June 1, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting 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 compliance with the regulation regarding maintaining a complete and accurate accounting of controlled medications. The facility's plan of correction for a deficiency regarding the accuracy of residents' clinical records, cited during the survey ending June 1, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F842, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding maintaining accurate clinical records. Refer to F656, F684, F755, F842 28 Pa. Code 201.14(a) Responsibility of Licensee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 19 of 21 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 06/05/2024 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)

F 0867 28 Pa. Code 201.18(e)(1) Management. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 20 of 21 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 06/05/2024 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)

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of policies and personnel files, as well as staff interviews, it was determined that based on nurse aides' hire dates, the facility failed to ensure that nurse aides completed at least 12 hours of inservice education for one of five nurse aides reviewed (Nurse Aide 6). Findings include: The facility's policy regarding nurse aide inservice training, dated May 6, 2024, indicated that the facility will maintain an ongoing educational program for the development and improvement of skills of the facility's personnel, including at a minimum, annual in-service training. Certified Nursing Assistants are required to complete at a minimum 12 hours total annually. Nurse aide education records revealed that based on their hire dates Nurse Aide 6 did not have at least 12 hours of education annually as follows: Nurse Aide 6's hire date was May 18, 2018, and inservice records revealed that she had no annual education completed between May 2022 and May 2024. Interview with the Human Resources Director on June 5, 2024, at 10:40 a.m. confirmed that Nurse Aide 6 did not have the required 12 hours of annual education based on her hire date. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 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 21 of 21