Health inspection·December 26, 2024

F 0550 28 Pa. Code 201.29(j) Resident Rights. 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 2 of 6 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 12/26/2024 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)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to ensure personal privacy for one of six resident reviewed (Resident 2). Residents Affected - Few Findings include: The facility's policy regarding Resident Rights, dated May 6, 2024, revealed that the facility would protect and promote the rights of each resident, particularly those rights that pertain to a dignified existence. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 3, 2024, revealed that the resident was always understood, always understood others, was cognitively impaired, and required assistance from staff for daily care needs. Observations of Resident 2 on December 26, 2024, at 8:36 a.m. revealed that the resident had no curtain or blind covering the window to the outside. His bed was on the window side of the room, and the window faced the facility's main parking lot. Interview with Resident 2 on December 26, 2024 at 8:36 a.m. revealed that he has asked for a curtain or blind for his window because he uses the urinal and the bedside commode and dresses himself, and he feels exposed to the parking lot. He stated that he is not able to pull his privacy curtain around his bed because it is located behind his bed on the window side of the bed, and he is not physically able to grab it. He further stated that he does not like his privacy curtain pulled closed at all times because he likes to watch his TV and likes to be able to look outside. Interview with the Director of Housekeeping on December 26, 2024, at 8:53 a.m. revealed that blinds have been ordered for Resident 2's and Resident 6's windows, but they have not arrived yet. She was not sure how long the rooms have been without curtains or blinds. 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 3 of 6 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 12/26/2024 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)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed for an injury of unknown origin, to rule out that abuse and/or neglect were involved for one of five residents reviewed (Resident 5). Residents Affected - Few Findings include: The facility's policy regarding abuse and neglect, dated May 6, 2024, indicated that the Director of Nursing/designee conducts the investigation. Reviews the accident/incident report; obtains written statements of staff assigned to the resident for the shift during which the allegation is noted, and 24 hours prior if indicated; and interviews witnesses, if any, and obtains statements. The facility's policy regarding incident/accident reporting, dated May 6, 2024, indicated that in the case of an incident or injury of unknown etiology, an investigative report of injury unknown origin and investigative report of skin tear/bruise of unknown etiology are completed, as needed. All employees assigned to the resident involved in an incident/accident will fill out the employee statement form. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 1, 2024, revealed that the resident was understood, could understand others, with a Brief Interview for Mental Status (BIMS -a structured cognitive interview) of 02 indicating that the resident had a severe cognitive impairment, and had a diagnosis which included Alzheimer's disease and Parkinson's disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns). A care plan for the resident, dated June 10, 2024, revealed that the resident tends to refuse care/medications. A readmission assessment for Resident 5, dated November 13, 2024, revealed that the resident returned to the facility after an admission to the hospital. Her upper extremities had no edema (a medical condition that occurs when fluid builds up in the body's tissues, causing swelling) and scattered bruising was noted to the resident's hands and arms. A skin assessment for Resident 5, dated November 16, 2024, revealed that the resident had multiple small bruises noted to her bilateral hands. No other areas noted. A physician's note for Resident 5, dated November 19, 2024, revealed that the resident was seen due to being readmitted to the facility for problems of confusion, pneumonia, and sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury). That her mental status is back to her baseline, and her extremities had no edema. A nursing note for Resident 5, dated November 19, 2024, revealed that the resident was noted to have an increase in pain to her right wrist, as well as swelling. The resident has multiple bruises to her bilateral hands and arms from a previous hospitalization. The resident was in therapy and complained of the increased pain with movement. Investigation documents for Resident 5, dated November 19, 2024, revealed the writer was called to the therapy department due to the resident complaining of pain to her right hand/wrist with movement. Slight swelling of the wrist area was noted. Fingers were warm and had a positive radial pulse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 4 of 6 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 12/26/2024 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm The resident had light, yellow bilateral bruising of the arms and hands from readmission from the hospital. The resident is unable to verbalize what happened. A witness statement completed by Nurse Aide 3, dated November 19, 2024, revealed that she did not work with Resident 5. Residents Affected - Few A witness statement completed by Nurse Aide 2, dated November 19, 2024, revealed that she did not have any contact with Resident 5. There was no documented evidence that the facility's investigation was expanded to include interviews with all staff who had potential contact with Resident 5 in and around the time that the resident complained of pain and swelling to her right wrist on November 19, 2024. Interview with the Director of Nursing on December 26, 2024, at 1:32 p.m. confirmed that she had no documented evidence that the investigation was expanded to include interviews with all staff who had potential contact with Resident 5 in and around the time that the resident complained of pain and swelling to her right wrist on November 19, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 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 6 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 12/26/2024 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)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure that peripherally-inserted central catheters (PICC lines) site dressings were changed per physician's orders for one of six residents reviewed (Resident 2). Residents Affected - Some Findings include: The facility's policy regarding PICC line maintenance and care, dated May 6, 2024, indicated that staff are to change the dressing every week. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 3, 2024, revealed that the resident was always understood, always understood others, was cognitively impaired, required assistance from staff for daily care needs, and that he was receiving intravenous medications (IV). Physician's orders for Resident 2, dated December 18, 2024, included and order for the resident to have the PICC line dressing changed every week. Review of Resident 2's Medication Administration Record (MAR), dated December 2024, revealed that staff had not documented the resident's PICC line dressing change in the month of December. Observations of Resident 2 on December 26, 2024, at 8:34 a.m. revealed that his PICC line dressing was dated December 13, 2024 and that it was not sticking to his arm and that he had cut the cuff off one of his socks and put it around his arm to hold the PICC line dressing in place. Interview with Resident 2 on December 26, 2024, at 8:34 a.m. revealed that he had not had his PICC line dressing changed since December 13, 2024. He stated that he had been asking them to change it because the current one was not sticking and he was concerned it would fall off and the PICC line would get pulled out. Interview with Registered Nurse 1 on December 26, 2024, at 8:53 a.m. revealed that his PICC line dressing should have been changed weekly and that she was not sure why there were no dressings available to change it. Interview with the Director of Nursing on December 26, 2024, at 10:34 a.m. revealed that Resident 2's PICC line dressing was on back order from the pharmacy and that she was not sure why it was not obtained from another source. She stated that Resident 2's PICC line dressing should have been changed per the physician's orders. 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 6