Maple Winds Healthcare and Rehabilitation, LLC

In the surveyor’s words

From the most serious findings on record at Maple Winds Healthcare and Rehabilitation, LLC, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 30, 2022

  Based on a review facility policy and clinical records, as well as interviews with staff, it was determined that the facility failed to ensure that residents who were at risk for developing pressure ulcers received care to prevent them by failing to follow orthopedic recommendations and failing to clarify an order for one of five residents reviewed (Resident 2), resulting in harm to the resident who developed a pressure ulcer with subsequent amputation. Findings include: The facility's policy regarding pressure ulcer prevention and management, dated January 26, 2022, revealed that the facility was to assess residents on admission and as needed for the risk of pressure ulcers and as needed for risk factors associated with pressure ulcer development. […]

• No harm, potential for more than minimal, widespreadF812Jul 2, 2025

  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. 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. […]

• No harm, potential for more than minimal, widespreadF803Jun 5, 2024

  Based on review of the facility's written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu. Findings include: A facility's policy regarding menu management, dated May 6, 2024, revealed that menus were to be posted on menu boards located in the dining room and hallway. Temporary changes to the menu will be posted daily on the menu boards. To ensure consistency, all meals served will strictly adhere to the pre-approved menus. The facility's written and posted weekly menu for the lunch meal on June 3, 2024, revealed that the residents were to receive bread with margarine. Observations during the lunch meal on June 3, 2024, at 12:08 p.m. […]

• No harm, potential for more than minimal, patternF605May 18, 2026

  Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of a psychotropic medication for one of 21 residents reviewed (Resident 5). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 8, 2026, revealed that the resident was cognitively impaired, was taking an anti-anxiety medication, and had a diagnosis of anxiety. […]

• No harm, potential for more than minimal, patternF658May 18, 2026

  Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's orders for two of 21 residents reviewed (Resident 8, 48). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. […]