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Health Inspection

Maple Heights Health & Rehab Center, Llc

January 30, 2025 · Ebensburg, PA · 429 Manor Drive
Citations 10
CMS Rating 1/5
Beds 301
Provider ID 395828
Healthcare Facility
Maple Heights Health & Rehab Center, Llc
Ebensburg, PA  ·  View full profile →
Inspection Summary

Maple Heights Health & Rehab Center, LLC in EBENSBURG, PA — inspection on January 30, 2025.

Found 10 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF600
Minimal harm or Few Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff affected

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.

395828

Form Approved OMB

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

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.

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

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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

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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.

395828

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EBENSBURG, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Maple Heights Health & Rehab Center, LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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