Pennsylvania Department of Health
MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC
Patient Care Inspection Results

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MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC
Inspection Results For:

There are  93 surveys for this facility. Please select a date to view the survey results.

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MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on January 26, 2024, it was determined that Maple Winds Healthcare and Rehabilitation, LLC was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of transfer for three of three residents reviewed (Residents 1, 2, 3).

Findings include:

The facility's policy regarding bed holds (holding a resident's bed while the resident is absent from the facility for hospitalization), dated October 6, 2023, indicated that the admission director/designee will contact the resident/resident's representative following a facility-initiated transfer to an acute care facility or hospital. The original copy of the facility's bed-hold policy was to be placed in the resident's chart and the copy can be given to the family. This can be in person or sent via email. If the representative is present, then they can be informed at that time. Then document in the resident's electronic medical record that the resident/representative was notified either via phone call or in person and received a copy and the original was placed in the chart. When making a phone call to the resident/resident representative to inform them of their options, indicate their choice made on the form. Document on the form that the call was made, and the date and time of the call.

Nursing notes for Resident 1, dated January 8, 2024, revealed that the resident was admitted to the hospital on this date. However, there was no documented evidence that a written copy of the facility's bed-hold policy was provided to the resident and/or responsible party at the time of his transfer to the hospital.

Nursing notes for Resident 2, dated December 30, 2023, revealed that the resident was admitted to the hospital on this date. However, there was no documented evidence that a written copy of the facility's bed-hold policy was provided to the resident and/or responsible party at the time of her transfer to the hospital.

Nursing notes for Resident 3, dated August 9, 2023; November 17, 2023; December 3, 2023; and December 16, 2023, revealed that the resident was admitted to the hospital on those dates. However, there was no documented evidence that a written copy of the facility's bed-hold policy was provided to the resident and/or responsible party at the time of his transfers to the hospital.

Interview with the Nursing Home Adminstrator on January 26, 2024, at 1:20 p.m. confirmed that a copy of the facility's bed-hold policy was not provided to Residents 1, 2 and 3 or their responsible parties at the time of their transfers to the hospital.

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

28 Pa. Code 201.18(b)(3) Management.





 Plan of Correction - To be completed: 03/04/2024

Resident 1 no longer resides in the facility.

Copy of the facility's bed-hold policy was reviewed and provided to Resident 2's responsible party.

Copy of the facility's bed-hold policy was reviewed and provided to Resident 3's responsible party.


Residents who have a transfer to the hospital have the ability to be affected by this alleged deficient practice.

A whole house audit on residents recently transferred to the hospital was completed to ensure a copy of the facility's bed-hold policy was provided to resident and/or responsible party at time of his/her transfer to the hospital.

Admission Director and Social Services Director re-educated by Nursing Home Administrator/designee on contacting the resident/resident's representative following a facility-initiated transfer to an acute care facility or hospital, including the need to place original copy of the facility's bed-hold policy in the resident's chart and the copy given to the family with documentation placed in resident's electronic medical record that the resident/resident's representative was notified via phone call or in person and received copy with original placed in the chart.


Facility-initiated transfers to acute care facilities or hospitals will be audited weekly times four weeks then monthly times three months by the Director of Nursing/designee to ensure resident's electronic medical record contains documentation that the resident/resident's representative was notified via phone call or in person and received copy of facility bed-hold policy with original placed in the chart.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.




483.15(e)(1)(2) REQUIREMENT Permitting Residents to Return to Facility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid
nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.

§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
Observations:


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of three residents reviewed (Resident 1).

Findings include:

The facility's policy regarding notice requirements for transfer/discharge of a long-term resident, dated October 6, 2023, indicated that the facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident, or the health of individuals in the facility would otherwise be endangered. The facility must also be sure to document the danger that failure to transfer or discharge would pose.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 27, 2023, revealed that the resident was understood, understands, exhibited no behaviors, and had diagnoses that included osteomyelitis (a serious infection of the bone that can be either acute or chronic), diabetes, chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), and aquired absence of the right great toe.

A nursing note for Resident 1, dated December 20, 2023, revealed that the resident arrived around 12:45 p.m. via med van in a wheelchair and was alert but confused.

Nursing notes for Resident 1, dated December 27, 28, and 30, 2023, and January 3 and 4, 2024, revealed that the resident was being noncompliant with his nonweight bearing status to his right leg and when staff attempted to re-educate and re-direct him, he would become agitated and threaten them.

Nursing notes for Resident 1, dated January 6 and 7, 2024, revealed that the resident was being more cooperative with his nonweight bearing status to his right leg.

A nursing note for Resident 1, dated January 8, 2024, at 1:59 a.m. revealed that the resident has continuously and purposely gotten out of his bed and gone down to his knees beside his bed on his fall mat and
awaits staff intervention (requesting to lift him up). He was assisted to his wheelchair and he was taken to the nurses' station for close observation. The resident would then get up on his own without assistance, would not allow staff to assist him, and states that the staff don't know what the f**k they are doing. At least four staff persons, including this writer, attempted to educate him about his risk of falling and hurting himself, and the safety issues, as well as his increased risk for infection with his foot and walking on a dirty floor with no socks or foot covering. For safety reasons and his continued noncompliance and intentional acting-out behaviors, he will have included in his care plan that he is able to put himself on the fall mat beside his bed. A nursing note at 3:31 a.m. revealed that the nurses responded to the resident's room for the bed alarm sounding between approximatley 3:30 a.m. and 4:00 a.m. and the resident was kneeling on the floor. Incontinent care was provided at that time. Approximately five minutes later the bed alarm sounded again, and nursing staff responded to find him kneeling on the floor again. An order was obtained to transport the resident to the hospital for continuing to possibly harm himself as well as having an acute change in mental status. Emergency services (9-1-1) was contacted and the resident was transported out of the facility at approximately 4:30 a.m. A nursing note at 10:18 a.m. revealed that the resident was being admitted to the hospital with a diagnosis of altered mental status and toe infection.

There was no documented evidence that the facility could not meet Resident 1's needs related to behaviors, and no documented evidence that the resident's discharge was based on a valid discharge reason. The facility did not wait until he was treated and discharged from the hospital to determine if the facility could not meet the resident's needs.

Interview with the Director of Nursing on January 26, 2024, at 2:15 p.m. confirmed that there was no documented evidence in the clinical record of the reasons why the facility was not able to meet the resident's needs. She indicated Resident 1 was very noncompliant and was wandering in other residents' rooms as well as being verbally aggressive toward staff. He also threatened to "punch me in the f*****g face" when I was just trying to get him a drink. We did talk about it as a team and with the physician that we were not able to meet his care needs here at the facility, and that is why it was decided that he would not be able to return here.

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

28 Pa. Code 201.18(b)(1)(3) Management.


 Plan of Correction - To be completed: 03/04/2024

Resident 1 no longer resides in the facility.


Residents who reside in the facility and are transferred/discharged from the facility have the ability to be affected by this alleged deficient practice.

Audit of residents recently transferred/discharged from the facility was completed to ensure facility permitted each resident to remain in the facility and did not
transfer or discharge the resident from the facility
unless the transfer or discharge was necessary for the resident's welfare and the resident's needs were not able to be
met in the facility, the safety of individuals in the
facility were endangered due to the clinical or
behavioral status of the resident or the health of
individuals in the facility would otherwise be
endangered.


Director of Nursing re-educated on Notice Requirements for Transfer/Discharge of a Long-Term Resident, including the need to document the danger that failure to transfer or discharge would pose.

Audits will be performed by the Nursing Home Administrator/designee weekly times four weeks then monthly times four months to ensure any resident not permitted to remain in the facility and transferred/discharged has documentation indicating danger that failure to transfer or discharge would pose.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of three residents reviewed (Resident 1).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 27, 2023, revealed that the resident was understood, understands, and had a diagnosis which included osteomyelitis (a serious infection of the bone that can be either acute or chronic) and aquired absence of the right great toe.

A wound healing center note for Resident 1, dated January 2, 2024, revealed that staff was to leave the dressing on the resident's foot for three days and then apply betadine dressings daily.

Review of Resident 1's Treatment Administration Record (TARs) for January 2024 revealed that staff completed the betadine dressing to the resident's right foot on January 5, 2024. However, there was no documented evidence that the betadine dressing was completed on January 6 and 7, 2024, as per the wound healing center's recommendations.

Interview with the Director of Nursing on January 26, 2024, at 12:00 p.m. confirmed that there was no documented evidence that the betadine dressing was completed as per the wound healing center's recommendations on January 6 and 7, 2024.

Interview with Registered Nurse 1 on Janaury 26, 2024, at 1:30 p.m. revealed that she completed the betadine dressing to Resident 1's right foot on January 6 and 7, 2024. She indicated that she recalls that the resident was always noncompliant and standing on that foot and that the dressing was off his foot on the 6th, so she went in and completed the treatment. She indicated that she also completed the treatment on the 7th as well.

28 Pa. Code 211.5(f) Clinical records.

28 Pa. Code 211.12(d)(3)(5) Nursing services.


 Plan of Correction - To be completed: 03/04/2024

Resident 1 no longer resides in the facility.

Any resident who receives physician treatment orders for dressings and/or dressing changes has the ability to be affected by this alleged deficient practice.

A whole house audit on residents with treatment orders for dressings/dressing changes was completed to ensure documentation of dressing completion and/or dressing change was completed and present in the medical record.

Licensed Nursing Staff , including Agency Licensed Staff, re-educated on the importance of documenting dressing completion and/or dressing change as per physician orders in the medical record.

The Director of Nursing/designee will audit treatment administration records for residents who are to receive dressings/dressing changes weekly times eight weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.


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