Inspection·June 2, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clinical records review failed to reveal that a follow-up call/message was sent to the practitioner. Clinical records failed to reveal that the practitioner had received, reviewed, and acknowledged the message sent via secure conversation. Interview conducted with licensed nurse Employee E4 on June 1, 2023; revealed she/he was a regular evening shift nurse of Resident 92. Employee E4 reported approximately 7:00 p.m., the resident's temperature was 101 F. The nurse continued to relay that she/he checked the resident's baseline vitals and confirmed that the temperature was elevated from the baseline. Employee E4 confirmed that she/he never received any previous report of elevated temperature for the resident, and this was the first time he/she had a temperature of 101 F while caring for the resident. Employee E4 confirmed that the elevated temperature was a change in condition for the resident. The nurse notified the nursing supervisor of the resident's condition and administered with needed Tylenol for the fever. Employee E4 reported that the nursing supervisor had reached out to the provider but was not sure of the mode of notification. Employee E4 reported that it was the facility's protocol to notify the nursing supervisor and they are the one who notifies the NP/MD. Employee E4 reported that the incoming shift reported the resident's condition. Review of Resident 92'a May 2023, Medication Administration Record (MAR) revealed Resident 92 was administered with Acetaminophen 500 mg extra strength two tablets (1000mg) on May 16, 2023, at 7:44 p.m. Interview conducted with licensed nurse Employee E5 on June 1, 2023 revealed he/she was the nursing supervisor on May 17, 2023, morning shift. Employee E5 explained that the Secure Conversation are messages sent to the nurse practitioner and used for issues like medications. Employee E5 confirmed that for a resident's significant change in condition, the on-call physician should have been called. Employee E5 reported that upon reading the secure conversation indicating that the resident had an elevated temperature the night before and still with an elevated temperature in the morning, the physician who was in the building was notified. Review of the physician's notes dated May 17, 2023, at 8:50 a.m., revealed resident developed a fever of 101.5 F last night and was given Tylenol, for some reason the on-call physician was not notified of the fever last night. This morning the resident is weak, has a slight cough, and is having difficulty getting out of bed when he/she was prior independent. Spoke with the physical therapist and nurse and they noticed significant change. Resident appears flushed and warm, heart rate was 120 /min., and his temperature is 101F. The Resident complained of slight back pain today, seemed thirsty, appears dyspneic (short of breath), and has a slight cough with some clear mucus. Review of the nursing progress notes dated May 17, 2023, at 11:23 a.m., revealed resident was assessed by the physician and continued with a fever of 100.1 F, the physician ordered to send the resident to the ER (Emergency Room) for evaluation and treatment, 911 was called, the wife was notified. Review of the hospital records and discharge summary revealed resident was admitted to the hospital on [DATE], with admitting diagnosis of Sepsis - (The body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage, and death). The problem list revealed sepsis end-organ dysfunction suspected secondary to residual fluid collections, and peritonitis (inflammation of the membrane lining of the abdominal wall and covering abdominal organs) after recent bowel perforation. Possibly UTI (urinary tract infection). Followed by an Infectious Disease doctor and treated with antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396128 If continuation sheet Page 2 of 3 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 396128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Farm 604 Oak Street Akron, PA 17501 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 Residents Affected - Few Interview conducted with the Director of Nursing (DON) on June 2, 2023, at 11:00 a.m. confirmed there was no documented evidence the on-call physician was notified of the resident's elevated temperature on the night of May 16, 2023. Clinical records review revealed a Secure Conversation was sent to the NP (Nurse Practitioner) instead calling the on-call physician on the night of June 16, 2023, for Resident 92's complaint of not feeling well, back pain, and elevated temperature. The facility failed to ensure Resident 92's change in condition, elevated temperature was appropriately communicated with the physician. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident Care Policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396128 If continuation sheet Page 3 of 3