Cambria Care Center

F-F600, revealed that the facility's QAPI committee was ineffective in maintaining compliance with preventing resident abuse/neglect.

The facility's plan of correction for a deficiency regarding timely completion of comprehensive assessments, cited during the survey ending February 14, 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

F-F636, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding timely completion of comprehensive assessments.

The facility's plan of correction for a deficiency regarding a failure to ensure that MDS assessments were accurate upon submission, cited during the survey ending February 14, 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

F-F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 37 395828 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395828 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931

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 The facility's plan of correction for a deficiency regarding the development of a comprehensive person-centered care plan, cited during a survey ending February 14, 2024, revealed that audits would be Level of Harm - Minimal harm or completed. The results of the current survey, cited under

F-F656, revealed that the QAPI committee was potential for actual harm ineffective in correcting deficient practices related to the development of a comprehensive person-centered care plan. Residents Affected - Some

The facility's plan of correction for a deficiency regarding professional nursing services, cited during the survey ending February 14, 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

F-F658, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding professional nursing services.

The facility's plans of correction for deficiencies regarding providing a safe environment free of accident hazards, cited during the surveys ending February 14 and August 1, 2024 revealed that the facility developed plans 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

F-F689, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to safety and accident-free environments.

The facility's plans of correction for deficiencies regarding the failure to account for the physician and certified registered nurse practitioner (CRNP) writing progress notes with each visit, cited during the surveys ending February 14, 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

F-F711, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the physician and the CRNP writing progress notes with each visit.

The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the surveys ending February 14, 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

F-F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

The facility's plan of correction for a deficiency regarding storing/labeling medications properly, cited during

the survey ending February 14, 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

F-F761, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to storing/labeling medications properly.

The facility's plans of correction for deficiencies regarding infection control practices, cited during the surveys ending February 14 and June 20, 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

F-F880.

28 Pa. Code 201.14(a) Responsibility of Licensee.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 37 395828 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395828 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931

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 28 Pa. Code 201.18(e)(1) Management.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 37 395828 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395828 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931

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 31760 potential for actual harm Based on review of established infection control guidelines, facility policy, and residents' clinical records, as Residents Affected - Few well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 66 residents reviewed (Resident 79).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP's) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP's

during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP's, dated December 30, 2024, indicated that EBP's are infection control interventions designed to reduce the transmission of MDRO's through gown and glove use by HCP in the long-term care settings in accordance with CDC's consideration for use of EBP in skilled nursing facilities. EBP are recommended during high contact care (e.g. dressing, bathing, transferring, changing brief or assisting with toileting, device care, wound care, ect.) activities with residents who are at high risk of acquiring or spreading an MDRO (e.g. residents with indwelling medical devices or wounds).

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated November 21, 2024, revealed that the resident was understood, could understand others, had a indwelling catheter (a thin, flexible tube inserted into the urinary bladder to collect and drain urine), and had a diagnosis of quadriplegia (a condition characterized by the partial or complete loss of motor function, sensation, and autonomic control in all four limbs (arms and legs)).

Physician's orders for Resident 79, dated December 29, 2024, included an order for the resident to be on EBP's.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 37 395828 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395828 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931

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 Observations of Resident 79's room on January 27, 2025, at 10:29 a.m. revealed that there was signage on

the resident's door indicating that the resident was on EBP's and that staff was to wear gloves and gown for Level of Harm - Minimal harm or the following high contact resident care activities: dressing, bathing showering, transferring, changing linens, potential for actual harm changing briefs or assisting with toileting, direct care or use central line (a flexible tube inserted into a large vein near the heart), urinary catheter, feeding tube, tracheostomy (a surgical procedure that creates an Residents Affected - Few opening (stoma) in the front of the neck into the trachea (windpipe)), wound care, and any skin opening requiring a dressing.

Observations on January 28, 2025, at 11:54 a.m. revealed that Nurse Aide 11 was at Resident 79's bedside emptying the resident's indwelling catheter drainage bag into a clear plastic container. However, while emptying the resident's indwelling catheter drainage bag, she only wore gloves and did not wear a gown.

She then performed hand hygiene, placed gloves on, and then assisted the resident to reposition in bed.

Interview with Licensed Practical Nurse/Infection Control Preventionist on January 28, 2025, at 12:17 p.m. confirmed that Resident 79 was on EBP, and that Nurse Aide 11 should have been wearing a gown and gloves while emptying the resident's indwelling catheter drainage bag and while assisting the resident to reposition in bed.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 37 395828 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395828 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Heights Health & Rehab Center, LLC 429 Manor Drive Ebensburg, PA 15931

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 46994 potential for actual harm Based on observations and staff interviews, it was determined that the facility failed to ensure that essential Residents Affected - Some equipment was in safe operating condition in the facility's kitchen.

Findings include:

Observations in the facility's kitchen on January 29, 2025, at 9:38 a.m. revealed that the first rinse cycle on

the dishwashing machine was not registering a temperature during dishwashing and that water was leaking onto the floor from underneath the dishwasher. A steam kettle with a plastic bucket underneath it was catching water that was leaking.

Interview with the Dietary Manager on January 30, 2024, at 11:15 a.m. revealed that the dishwasher was washing dishes correctly and providing the final sanitizing rinse that was required; however, it had been leaking water and not properly functioning to full capacity since September 2024. The Dietary Manager also revealed that the steam kettle has been broken since June 2024 and needs a new seal; an upright cooler has been out of service since May 2024; the garbage disposal was not being used because it was making a loud noise when turning it on; one oven was not in use since March 2024 because the door pin snapped off;

the second oven had a broken on/off switch but was able to be used; one of the two pressure cookers has been out of service because of a bad element since August 2024; and the second pressure cooker has been broken and unable to be repaired since September 2024. Alternate cooking equipment was being used in place of the steamers, and there has been no adverse effects on the meal service related to the broken equipment.

Interview with the Nursing Home Administrator on January 30, 2025, at 12:36 p.m. confirmed that the above-mentioned kitchen equipment was not operating properly or not operating at all, and that the facility was in the process of repairing or replacing the kitchen equipment that was not operating correctly.

28 Pa. Code 201.18(b)(3) Administrator's Responsibility.

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