Inspection·July 11, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of manufacturer's directions for use, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to follow the manufacturer's directions for use of a high-back reclining wheelchair for one of three residents reviewed (Resident 1), resulting in a fall. Findings include: Operation instructions for the Medline Standard Manual Wheelchairs, dated December 30, 2021, revealed that to ensure safety in using this Medline wheelchair, all warnings and safety information and all instructions must be followed. Failure to do so may result in serious bodily injury or damage to the chair. Recliner models only: DO NOT use the recliner wheelchair without the anti-tip devices installed. Anti-tippers MUST be always attached, and both must be adjusted to the same height. Ensure the anti-tippers are secured as evidenced by the spring buttons fully protruding out of the holes. Anti-tippers (included with select models): Rear anti-tippers help keep the chair from tipping and are recommended attachments for additional safety. The use of anti-tippers is required on all recliner models. Recliner operation (recliner models only) WARNINGS: Anti-tippers MUST be always attached. Ensure both ant-tippers are adjusted to the same height. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 27, 2024, revealed that the resident was usually understood and could usually understand others, and had a diagnosis which included cerebral vascular accident (CVA commonly known as a stroke) and Parkinson's disease. A care plan for the resident, dated May 30, 2024, revealed that the resident had an actual skin impairment to his right second toe and right heel, and that the resident was to utilize a high-back reclining wheelchair with wedge cushion (gently tilts the hips, pelvis and spine forward) and foot buddy (cushioned back and side panels prevent feet from slipping off footrests) for out-of-bed positioning. An occupational therapy note for Resident 1, dated May 1, 2024, revealed that the resident demonstrated fair to poor positioning in a standard wheelchair with a foot buddy, wedge cushion, and backrest cushion. Resident 1 reported back pain and was requiring an adjustment in his wheelchair when assessed. The plan was to contact the medical supplier to acquire a high-back reclining wheelchair that the resident can self-propel with necessary back support. The current backrest support was not sufficient to reduce out-of-bed pain/discomfort. An occupational therapy note for Resident 1, dated May 23, 2024, revealed that the resident trialed a 20-inch high-back reclining wheelchair this date with good upright positioning following the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 396088 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 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)