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Inspection visit

Health inspection

MAPLE WINDS HEALTHCARE AND REHABILITATION, LLCCMS #39608817 citations on this visit
17 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 17 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician and the resident's responsible party regarding a change in condition for one of 35 residents reviewed (Resident 2). Findings include: The facility's policy regarding changes in a resident's condition or status, dated March 12, 2025, revealed that physicians, responsible family members or legal representatives would be notified as soon as possible of any changes in the resident's condition. A quarterly admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 31, 2024, revealed that the resident was cognitively intact and had diagnoses that included diabetes, congestive heart failure, and chronic obstructive pulmonary disease. A review of Resident 2's care plan, dated November 1, 2023, indicated that the resident had a history of acute (sudden onset) respiratory failure. A nursing note for Resident 2, dated November 13, 2025, at 6:17 p.m. revealed that when staff entered the resident's room to administer medications, the resident was found to be difficult to wake up and hard to arouse. Vital signs were as follows: blood pressure was 180/100, pulse 107, respirations 19, and oxygen saturation was 97 percent while on 4 liters per minute of oxygen, temperature was 96.3 degrees F. Resident 2 was pale and cold to touch with no sweating. The resident had no urine output, and the bladder was distended. The air conditioner was turned off and a blanket was placed on the resident to keep her warm. The registered nurse supervisor was informed. Resident 2 was placed on her BiPAP (Bilevel Positive Airway Pressure machine, a device that assists breathing by delivering pressurized air through a mask). Straight catheter was performed and drained around 650 milliliters of clear yellowish urine. Staff to continue to observe resident for any untoward events. There was no documented evidence in Resident 2's clinical record that the physician or her son was notified about her change in condition. A nursing note for Resident 2, dated November 18, 2025, at 12:55 p.m. revealed that Resident 2 became pale, unresponsive, and had profuse sweating. The resident had an oxygen saturation of 74 percent and was placed on the BiPAP machine. Resident 2's blood pressure was 110/60 with a temperature of 94.3 degrees. The physician was notified with an order to send to the hospital, and a voicemail was left for the resident's son. Interview with the Director of Nursing on July 1, 2025, at 1:14 p.m. confirmed that on November 18, 2025, Resident 2 had a change in condition similar to the event on November 13, 2025. However, on (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 23 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 07/02/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm November 18, 2025, the physician and son were notified of her declining health status, but on November 13, 2025, per facility policy, the physician and son should have been notified regarding the resident's change in condition, and they were not. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 2 of 23 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 07/02/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of policies and facility grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to follow its grievance policies regarding maintaining a log of all grievances received for one of 35 residents reviewed (Resident 13). Findings include: The facility's policy regarding grievances/complaints, dated March 12, 2025, indicated that a concern form is initiated when a concern/grievance is brought forward by a staff, family, responsible party and/or resident. After obtaining necessary information from the resident, family, responsible party and/or staff the concern form is completed and submitted to the Social Services Director or the Administrator who then distributes it to the appropriate depart head(s). The Social Service Director will log the form into a concern and grievance log. The Social Services Director will maintain a concern and grievance log as well as ensure concerns/grievances are completed and followed up with in a timely manner including effectiveness. Results of concerns/grievances will be maintained for a minimum of three years. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 13, dated April 9, 2025, revealed that the resident was understood and could understand others. A Grievance Form for Resident 13, dated June 14, 2025, revealed that the resident's daughter came to visit her mom and went into her room to find a dirty brief lying on the bottom of the bed. When she pulled back the covers, she found that her mom had no brief on, and that she was covered with a bowel movement, as well as her bed linens. Staff immediately went in and cleaned her up as well as her bedding. Staff was notified of the incident as well as the Director of Nursing. A Grievance Form for Resident 13, dated June 15, 2025, revealed that the resident's daughter reported that when she came in to visit the resident the other day (unsure of date) that there were some pills in a med cup on the resident's bedside table and that there were pills in her mom's bed, as well as on the floor. She stated that she did report this to the Director of Nursing. The registered nurses and licensed practical nurses were re-educated about not leaving medications or treatment supplies in residents' rooms. As of July 2, 2025, a review of the facility's complaint/grievance logs for June 2025 revealed no documented evidence that the concerns from Resident 13's daughter about finding the resident covered in a bowel movement and finding medications at the resident's bedside were listed on the facility's grievance/complaint log. Interview with the Director of Nursing on July 2, 2025, at 9:10 a.m. confirmed that there was no documented evidence as of July 2, 2025, that Resident 13's daughter's concerns about finding the resident covered in a bowel movement and finding medications at the resident's bedside was listed on the facility's grievance/complaint log. 28 Pa. Code 201.29(c.3)(4) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 3 of 23 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 07/02/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital, to ensure that a bed-hold notice was provided to the resident's responsible party and that the ombudsman was notified of the transfer to the hospital, for three of 35 residents reviewed (Residents 2, 19, 38), and failed to complete a post discharge summary for one of 35 resident's reviewed (Resident 37) Findings include: The facility's policy regarding bed-holds and returns, dated March 12, 2025, indicated that residents and/or representatives are informed (in writing) of the facility and bed-hold policies. An original is to be placed in the resident chart and one given to the family. The facility's policy regarding physician discharge summary revealed that when a resident is discharged the physician will complete and sign a discharge summary that includes the diagnosis, course of treatment, and pertinent test results. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 31, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included chronic obstructive pulmonary disease (a lung disease that causes decreased blood flow to the lungs). A nurse's note for Resident 2, dated November 13, 2025, at 6:17 p.m., revealed that the resident was difficult to wake up, had an elevated blood pressure of 180/100 with a temperature of 96.3. She was pale, cold to the touch, and was catheterized for a distended bladder. Resident 2's BiPAP machine (a type of non-invasive ventilation device used to help with breathing difficulties) was placed on her, and she was sent to the hospital where she was admitted for acute (sudden onset) respiratory failure. There was no documented evidence that written notification of transfer was provided to Resident 2 and the resident's representative, that a bed-hold notice was provided to the resident's responsible party, and that the ombudsman was notified of the transfer to the hospital as required. A quarterly MDS assessment for Resident 19, dated March 31, 2025, indicated that the resident was severely cognitively impaired, required assistance from staff for all daily care needs, and had a diagnoses that included Alzheimer's and Parkinson's disease and chronic obstructive pulmonary disease with a history of respiratory failure. Nursing notes for Resident 19, dated November 5, 2025, at 6:05 p.m., revealed that the resident was grey in color, lethargic and difficult to arouse, she was immediately transferred to the hospital and was admitted . There was no documented evidence that written notification of transfer was provided to the resident and the resident's representative, that a bed-hold notice was provided to the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 4 of 23 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 07/02/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible party, and no documented evidence that the ombudsman was notified of her transfer to the hospital as required. An admission MDS assessment for Resident 38, dated March 21, 2025, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included paraplegia with nerve damage to the bladder, acute and chronic respiratory failure, and pneumonia. Nursing notes for Resident 38, dated March 22, 2025, at 9:00 p.m., indicated that the resident was complaining of difficulty breathing and was unable to maintain oxygen rates above 80 percent on room air. He was hard to arouse, had abnormal lung sounds, and a productive cough of thick white mucus. The resident was transferred to the hospital. A nursing note, dated March 23, 2025, at 3:02 a.m., indicated that Resident 38 was admitted to the hospital with a diagnosis of sepsis (a life threatening response to an infection). There was no documented evidence that written notification of transfer was provided to the resident and the resident's representative, that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of his transfer to the hospital as required. Nursing notes for Resident 37 indicated that he was admitted on [DATE], with a diagnosis of parapneumonic effusion (fluid accumulation in the space between the lung and chest wall accompanied by pneumonia). He received physical therapy/strengthening at the facility, and on April 7, 2025, he was discharged back to his previous residence at a personal care home. There was no documented evidence that a discharge summary (an overview of the residents stay at the facility) was done by the physician as required. Interview with the Director of Nursing on July 2, 2025, at 2:19 p.m. confirmed that for Residents 2, 19 and 38 there was no written notification of hospital transfer provided to them or their representatives, that a bed-hold notice was not provided to their responsible party, and that the ombudsman was not notified of the transfer to the hospital as required. In addition, the Director of Nursing confirmed that there was no documented discharge summary post discharge from the facility for Resident 37 as required. 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 5 of 23 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 07/02/2025 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required timeframe for 10 of 35 residents reviewed (Residents 14, 26, 34, 43, 44, 139, 140, 141, 142, 143). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that for admission MDS assessments, the assessment completion date was to be no later than the resident's admission date plus 13 calendar days. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated May 12, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 19, 2025, which was one day late. An admission MDS assessment for Resident 26, dated May 21, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 29, 2025, which was two days late. An admission MDS assessment for Resident 34, dated May 26, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on June 2, 2025, which was one day late. An admission MDS assessment for Resident 43, dated May 7, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 19, 2025, which was six days late. An admission MDS assessment for Resident 44, dated May 26, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on June 2, 2025, which was one day late. An admission MDS assessment for Resident 139, dated April 23, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 1, 2025, which was two days late. An admission MDS assessment for Resident 140, dated May 12, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 19, 2025, which was one day late. An admission MDS assessment for Resident 141, dated May 12, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 19, 2025, which was one day late. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 6 of 23 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 07/02/2025 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An admission MDS assessment for Resident 142, dated May 18, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 29, 2025, which was four days late. An admission MDS assessment for Resident 143, dated May 19, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on June 12, 2025, which was eight days late. Interview with the Licensed Practical Nurse Assessment Coordinator (LPNAC - a licensed practical nurse who is responsible for assisting the registered nurse with the completion of MDS assessments) on July 1, 2025, at 9:38 a.m. confirmed that the admission MDS assessments listed above were not completed within the required timeframes. 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 7 of 23 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 07/02/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on a 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 two of 35 residents reviewed (Residents 1, 25). Residents Affected - Few Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415G1 Diuretic Medications was to be coded if the resident took the medication during the seven-day look-back period, and Section N0415K1 Anticonvulsant Medications was to be coded if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 1, dated May 21, 2025, included an order for the resident to receive 20-25 milligram (mg) of Lisinopril-hydrochlorothiazide (a combination antihypertensive-diuretic medication used to lower blood pressure) in the morning for hypertension (high blood pressure). Review of the Medication Administration Record (MAR) for Resident 1, dated May 2025, revealed that staff administered the 20-25 milligram (mg) of Lisinopril-hydrochlorothiazide every morning from May 21 through 31, 2025. However, an annual MDS assessment for Resident 1, dated, May 24, 2025, revealed that Section NO415G1 was not coded, indicating that the resident did not receive a diuretic medication during the seven-day look-back assessment period. Physician's orders for Resident 25, dated October 28, 2022, included an order for the resident to receive 100 mg of Dilantin (an anticonvulsant) every morning and at bedtime for seizures. Review of the Medication Administration Record (MAR) for Resident 25, dated April 2025, revealed that staff administered the 100 mg tablet of Dilantin to the resident every morning and every bedtime from April 1 through 30, 2025. However, a significant change MDS assessment for Resident 25, dated April 22, 2025, revealed that Section NO415K1 was not coded, indicating that the resident to did not receive an anticonvulsant medication during the seven-day look-back assessment period. Interview with the Director of Nursing on July 1, 2025, at 1:09 p.m. confirmed the Resident 1 and 25's MDS assessments listed above were coded incorrectly. 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 8 of 23 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 07/02/2025 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 35 residents reviewed (Resident 9). Findings include: A facility policy for Care Plans, dated March 12, 2025, indicated that the resident and his or her representative were encouraged to participate in the development and implementation of the resident's person-centered care plan. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 9, dated April 10, 2025, revealed that the resident was cognitively intact, required extensive assistance from staff with daily care tasks, and received an anticoagulant, antiplatelet, and diuretic medication. Physician's orders for Resident 9, dated September 9, 2024, included an order for the resident to receive 5 milligrams (mg) of Apixaban (anticoagulant-used to prevent blood clots) by mouth every morning and bedtime, 81 mg of Aspirin (antiplatelet) by mouth daily in the morning, and 20 mg of Lasix (diuretic) by mouth daily in the morning. There was no documented evidence that a care plan was developed to address Resident 9's individual care and treatment needs related to her use of anticoagulant, antiplatelet, and diuretic medications. Interview with the Director of Nursing on July 1, 2025, at 1:15 p.m. confirmed that a care plan to address the care needs related to Resident 9's need for anticoagulant, antiplatelet, and diuretic medication use was not developed 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 9 of 23 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 07/02/2025 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 - Some 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for one of 35 residents reviewed (Resident 13). Findings include: The facility's policy regarding care plans, dated March 12, 2025, indicated that each resident will have an individualized interdisciplinary plan of care in place. The comprehensive care plan will 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 and/or resident's representative. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 13, dated April 9, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included obstructive uropathy (a condition where there is a blockage in the urinary tract, preventing normal urine flow). A care plan for the resident, dated February 11, 2025, revealed that the resident had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine); however, on April 16, 2025, the care plan was resolved due to the resident not requiring to have an indwelling urinary catheter any longer. Physician's orders for Resident 13, dated April 15, 2025, included an order for staff to discontinue the use of the resident's indwelling urinary catheter. Review of Resident 13's clinical record including nurse aide documentation revealed that the resident has frequently been incontinent of bladder. However, as of July 2, 2025, there was no documented evidence that Resident 13's care plan was revised/updated to reflect that the resident was incontinent of bladder since the removal of her indwelling urinary catheter on April 15, 2025. Interview with the Director of Nursing on July 2, 2025, at 8:44 a.m. confirmed that there was no documented evidence that Resident 13's care plan was revised/updated to reflect that the resident was incontinent of bladder, since the removal of her indwelling urinary catheter on April 15, 2025. 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 23 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 07/02/2025 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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of 35 residents reviewed (Resident 12). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 20, 2025, revealed that the resident was understood, and could usually understand others. Physician's orders for Resident 12, dated May 20, 2025, included an order for the resident to receive one gram (gm) of Meropenem (an antibiotic to treat a variety of serious bacterial infections) intravenously (a medical process that administers fluids, medications and nutrients directly into a person's vein) every eight hours for a urinary tract infection for seven days (a total of 21 doses). Review of Resident 12's Medication Administration Records (MARs) for May 2025 revealed that staff documented as administering the one gm of Meropenem intravenously on May 22 at 2:00 p.m. and 10:00 p.m.; May 23 through May 27 at 6:00 a.m., 2:00 p.m. and 10:00 p.m.; and on May 28 at 6:00 a.m. and 2:00 p.m. (total of 19 doses). Interview with the Director of Nursing on July 2, 2025, at 10:45 a.m. confirmed that Resident 12 only received 19 of the 21 doses of IV Meropenem over seven days as ordered by the physician. 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 11 of 23 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 07/02/2025 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 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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible by failing to ensure that fall/injury prevention interventions were in place for one of 35 residents reviewed (Resident 9). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 9, dated April 10, 2025, revealed that the resident was cognitively intact, required extensive assistance from staff with daily care tasks, and had limited range of motion to her lower extremities. The resident's care plan, dated June 19, 2025, revealed that the resident was at risk for falls and indicated that fall mats were to be at bedside. A nursing note for Resident 9, dated June 13, 2025, at 2:50 a.m., revealed that the resident was found lying on the floor on the left side of her bed. New interventions included placing her bed in the lowest position and bilateral fall mats. Observations of Resident 9 on July 2, 2025, at 8:46 a.m. revealed that the resident was in bed and there were no fall mats on either side of her bed. Interview with the Director of Nursing on July 2, 2025, at 11:54 a.m. confirmed that Resident 9 should have had bilateral fall mats while in bed. 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 12 of 23 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 07/02/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure urinary output was monitored for one of 35 residents reviewed (Resident 1) who had an indwelling urinary catheter, and failed to ensure proper incontinent care was completed for one of 35 residents reviewed (Resident 13). Findings include: The facility's policy regarding urinary output, dated March 12, 2025, revealed that the volume of urine output was to be documented in the resident's chart or electronic medical record. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 24, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care tasks, had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine), and had diagnoses that included neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve condition). Physician's orders for Resident 1, dated May 26, 2025, included orders for a Foley catheter for neurogenic bladder. A care plan, dated June 24, 2024, revealed that staff were to monitor and document the resident's intake and output. Nurse Aide documentation for Resident 1, dated May and June 2025, revealed that staff was to document the resident's urine output each shift; however, there was no documented evidence that urine output was recorded on the first shift (6:00 a.m. to 2:30 p.m.) on May 13, June 11, 14, 16, and 20, 2025; on the second shift (2:00 p.m. to 10:30 p.m.) on May 21, June 9 and 20, 2025; and on the third shift (10:00 p.m. to 6:30 a.m.) on June 6 and 30, 2025. Interview with the Director of Nursing on July 2, 2025, at 10:23 a.m. confirmed that there was no urine output recorded for Resident 1 on the mentioned dates and times. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 13, dated April 9, 2025, revealed that the resident was understood and could understand others. A care plan for the resident, dated September 26, 2023, revealed that the resident had an Activities of Daily Living (ADL) self-care deficit related to her limited mobility, and that she required the assist of two staff with toileting. Nurse Aide tasks for Resident 13, for May and June 2025, revealed that staff was to document every two hours to indicate if the resident was continent or incontinent of bladder; however, there was no evidence that bladder continence or incontinence was documented on May 14 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; May 15 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; May 17 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; May 24 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; May 25 at 12:00 a.m., 2:00 a.m., and 4:00 a.m.; June 4 at 12:00 a.m., 2:00 a.m., and 4:00 a.m.; June 5 at 12:00 a.m., 2:00 a.m., and 4:00 a.m.; June 6 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; June 10 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; June 11 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; June 13 at 12:00 a.m., 2:00 a.m., and 4:00 a.m.; June 15 at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., and 8:00 p.m.; and June 25 at 8:00 a.m., 10:00 a.m., and 12:00 p.m. Nurse Aide tasks for Resident 13, for May and June 2025, revealed that staff was to document the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 13 of 23 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 07/02/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some application of barrier cream to the resident's buttocks; however, there was no documented evidence that staff applied the barrier cream to the resident's buttocks during the day shift on May 1, 15, 17, 24, and 26, 2025; during evening shift on May 1, and 2, 2025, and on June 3 and 15, 2025; and during the night shift on May 24, and 31, 2025, and on June 2, 3, 4, and 12, 2025. Interview with the Director of Nursing on July 1, 2025, at 1:38 p.m. confirmed that there was no documented evidence that Resident 13's bladder continence or incontinence was documented on the above dates and times, and that application of barrier cream to the resident's buttocks was applied on the above dates. 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 14 of 23 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 07/02/2025 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that intravenous catheters were flushed according to facility policy and failed to ensure that physician's orders for the care and maintenance of intravenous catheters were obtained for two 35 residents reviewed (Residents 9, 12). Residents Affected - Some Findings include: The facility's policy regarding midline (a thin, flexible tube inserted into a large vein in the upper arm to administer medication or fluids intravenously) maintenance and care, dated March 12, 2025, indicated that staff was to change the transparent dressing every week or as needed if soiled, damp and/or loose. Staff was flush the line according to the physician's orders. The policy regarding flushing the peripheral intravenous access (the insertion of a short, flexible catheter into a peripheral vein, typically in the hand or arm, to deliver medications, fluids or other therapies directly into the bloodstream), dated March 12, 2025, indicated that the following regimen should be used when flushing an intravenous catheter: Normal Saline flush (used to help prevent IV catheters from becoming blocked and also to help remove any medication that may be left at the catheter site), administration of medications or fluids, Normal Saline flush, and then Heparin flush (a medication used to maintain the openness of intravenous catheters) if ordered. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 9, dated April 10, 2025, revealed that the resident was cognitively intact, had a multi-drug resistant organism (bacteria that is resistant to multiple antibiotics), received an antibiotic, and had IV access. Physician's orders for Resident 9, dated April 10, 2025, included an order for the resident to receive 500 milligrams (mg) of Meropenem intravenously every shift for a urinary tract infection for 20 administrations, and 10 milliliters (mL) of Sodium Chloride 0.9 percent intravenously for a routine flush every shift. Review of Medication Administration Records (MARs) for Resident 9, dated April 2025, revealed that staff documented administering the 500 mg of Meropenem intravenously every shift from April 10, 2025, at 6:00 a.m. through April 16, 2025, at 2:00 p.m. However, there was no documented evidence that staff flushed Resident 9's peripheral IV with Normal Saline solution before and after the administration of the Meropenem. Interview with the Director of Nursing on July 2, 2025, at 10:42 a.m. confirmed that there was no documented evidence that Resident 9's IV was flushed with Normal Saline solution before and after the administration of the Meropenem on the above dates. Physician's orders for Resident 12, dated May 20, 2025, included an order for the resident to receive one gram (gm) of Meropenem (an antibiotic to treat a variety of serious bacterial infections) intravenously (a medical process that administers fluids, medications and nutrients directly into a person's vein) every eight hours for a urinary tract infection for seven days. A nursing note for Resident 12, dated May 22, 2025, revealed that the resident's midline was placed in her upper right arm without difficulty. A nursing note for Resident 12, dated May 29, 2025, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 15 of 23 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 07/02/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed that the resident's right upper arm midline was removed with no complications. There was no documented evidence that Resident 12's physician was contacted for orders regarding the care and maintenance of the resident's midline from May 22 through 29, 2025, when it was removed. Review of Medication Administration Records (MARs) for Resident 12, dated May 2025, revealed that staff documented as administering the one gm of Meropenem intravenously on May 22, 2025, at 2:00 p.m. and 10:00 p.m.; May 23 through May 27, 2025, at 6:00 a.m., 2:00 p.m. and 10:00 p.m.; and on May 28, 2025, at 6:00 a.m. and 2:00 p.m. However, there was no documented evidence that staff flushed Resident 12's midline with Normal Saline solution before and after the administration of the Meropenem. Interview with the Director of Nursing on July 2, 2025, at 10:42 a.m. confirmed that there was no documented evidence that Resident 12's physician was contacted for orders regarding the care and maintenance of the resident's midline from May 22 through 29, 2025, when it was removed, and that there was no documented evidence that the resident's midline was flushed with Normal Saline solution before and after the administration of the Meropenem on the above dates. 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 16 of 23 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 07/02/2025 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 - Few 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 maintain accountability for controlled medications (drugs with the potential to be abused) for one of 35 residents reviewed (Resident 25). Findings include: The facility's policy regarding disposal of narcotics, dated March 12, 2025, indicated that controlled/narcotic medications were to be destroyed in the presence of tow licensed nurses. The two nurses would count together the remaining amount of controlled/narcotic medications to be destroyed. Two nurses would sign and date the Control Drug Record upon witnessing the destruction of the controlled/narcotic medications, logging the amount of medications destroyed. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated April 22, 2025, revealed that the resident was cognitively impaired, received pain medication routinely and as needed, and received an opioid (a controlled pain medication). Physician's orders, dated April 18, 2025, included an order for the resident to receive a 12 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for chronic pain, and physician's orders, dated May 22, 2025, included an order for the resident to receive a 25 mcg Fentanyl patch to be applied every three days for chronic pain. Review of Resident 25's Medication Administration Record (MAR) for May and June 2025 revealed that a Fentanyl patch was applied to the resident on May 3, 6, 9, 12, 15, 18, 21, 25, 28, and 31, and June 3, 6, 9, 12, 15, 18, and 21, 2025. A controlled drug count record (tracks each dose of a controlled medication) for Resident 25's Fentanyl patches revealed that one patch was signed out on the controlled drug log on May 3, 6, 9, 12, 15, 18, 21, 25, 28, and 31, and June 3, 6, 9, 12, 15, 18, 21, 2025. There was no documented evidence that two staff members signed that the old patch was destroyed after removal on these dates. Interview with the Director of Nursing on July 2, 2025, at 9:06 a.m. confirmed that there were not two witness signatures for the destruction of Fentanyl patches on the dates listed above. 28 Pa. Code 211.9(a)(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 17 of 23 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 07/02/2025 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 facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen and dry storage room was dated once opened. Residents Affected - Many Findings include: The facility policy regarding food storage, dated March 12, 2025, revealed that any food item once opened should be labeled with an open date. Observations in the dry storage room on June 30, 2025, at 8:53 a.m. revealed that there was one 10-pound bag of pasta that was opened and not dated with an open date. Observations in the kitchen refrigerator on June 30, 2025, at 9:01 a.m. revealed two opened and undated 5-pound bags of cheese, one with parmesan and the other with a mixture of cheddar and mozzarella. Observations in the kitchen on June 30, 2025, at 9:07 a.m. revealed that there was approximately ten pounds of flour and twenty-five pounds of rice that were opened and not labeled with an open date. Interview with the Dietary Manager and Director of Nursing on June 30, 2025, at 8:45 a.m. and 11:32 a.m. respectively, confirmed that all open food items in the kitchen should be labeled with a date once they are opened. 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 18 of 23 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 07/02/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 35 residents reviewed (Resident 25) who were receiving hospice services. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated April 22, 2025, indicated that the resident was cognitively impaired, received hospice services, and had a diagnosis of cancer. Physician's orders and a care plan for Resident 25, dated April 15, 2025, included an order for the resident to be treated by hospice (end-of-life services) for basal cell carcinoma (skin cancer) of the left upper limb. As of July 1, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained updated hospice nurse aide or registered nurse charting. The last hospice nurse aide charting located on the resident's hospice chart was dated June 5, 2025, and the last registered nurse charting was dated June 3, 2025. Interview with the Director of Nursing on July 2, 2025, at 10:10 a.m. confirmed that Resident 25's hospice nurse aide and registered nurse charting was not in the resident's clinical record and/or in the hospice provider's clinical record, and 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 19 of 23 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 07/02/2025 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 maintain compliance with nursing home regulations 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) surveys ending June 5, July 11, and December 26, 2024, 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 July 2, 2025, identified repeated deficiencies related to care plan revisions; providing quality care; ensuring that the resident's environment was free from accident hazards; maintaining intravenous catheters; preventing issues with the accountability of controlled medications (drugs with the potential to be abused). The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the survey ending June 5, 2024, 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 F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding care plan revisions. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending June 5, 2024, 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 F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care. The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free of accident hazards, cited during the surveys ending on July 11, 2024 revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the environment was free of accident hazards. The facility's plan of correction for a deficiency regarding intravenous catheters, cited during the survey ending December 26, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F694, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding intravenous catheters. The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the surveys ending June 5, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 20 of 23 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 07/02/2025 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 deficient practices related to the accountability of controlled medications. Level of Harm - Minimal harm or potential for actual harm Refer to F657, F684, F689, F694, F755. 28 Pa. Code 201.14(a) Responsibility of Licensee. Residents Affected - Few 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 23 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 07/02/2025 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of policies and attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that all required members of the Quality Assurance Committee attended quarterly meetings. Residents Affected - Few Findings include: The facility's policy for Quality Assurance and Performance Improvement, dated March 12, 2025, revealed that meetings would be held at least quarterly and would include the Nursing Home Administrator, Director of Nursing, all department heads, a community member, and the Medical Director. Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that the Medical Director did not attend any meetings that were held during the first quarter of 2025. Interview with the Director of Nursing on July 2, 2025, at 2:30 p.m. confirmed that the Medical Director did not attend meetings of the Quality Assurance Committee that were held during the first quarter of 2025. 28 Pa code 201.18(b)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396088 If continuation sheet Page 22 of 23 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 07/02/2025 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, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administration for three of three residents observed (Residents 2, 29, 45). Residents Affected - Few Findings include: The facility's policy regarding hand hygiene, dated March 12, 2025, indicated that all employees were to follow the hand washing procedure, which included hand sanitizing, before preparing or handling medications, and after removing gloves. Observations during the medication pass in A hall on July 2, 2025, at 8:33 a.m. revealed that Licensed Practical Nurse 1 prepared Resident 45's medications and administered them. Without sanitizing her hands, she donned gloves and entered Resident 29's room and took the resident's blood pressure. She doffed her gloves and without hand sanitizing she prepared and administered Resident 29's medications. She then went to Resident 2's room and donned gloves and checked the resident's blood sugar. She doffed her gloves and without hand sanitizing she prepared the resident's medications, donned gloves and administered them. Licensed Practical Nurse 1 exited the resident's room and hand sanitized at the medication cart. Interview with Licensed Practical Nurse 1 on July 2, 2025, at 9:35 a.m. confirmed that she should have sanitized her hands between residents while doing the medication pass and after she removed her gloves. Interview with the Director of Nursing on July 2, 2025, at 9:53 a.m. confirmed that Licensed Practical Nurse 1 did not properly sanitize her hands during medication administration and after glove removal, and she 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 23 of 23

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Citations

17 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0641GeneralS&S Dpotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0694GeneralS&S Epotential for harm

    F694 - Parenteral Fluids

    Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  • 0755GeneralS&S Dpotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0628GeneralS&S Dpotential for harm

    F628 - Documentation

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  • 0636GeneralS&S Epotential for harm

    F636 - Resident Assessment

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  • 0849GeneralS&S Dpotential for harm

    F849 - Hospice services

    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  • 0867GeneralS&S Dpotential for harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0868GeneralS&S Dpotential for harm

    F868 - Quality assessment and assurance

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0585GeneralS&S Dpotential for harm

    F585 - Grievances

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

  • 0657GeneralS&S Epotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0690GeneralS&S Epotential for harm

    F690 - Incontinence

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

FAQ · About this visit

Common questions about this visit

What happened during the July 2, 2025 survey of MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC?

This was a inspection survey of MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC on July 2, 2025. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC on July 2, 2025?

Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.