Pennsylvania Department of Health
 MAPLEWOOD NURSING AND REHABILITATION CENTER
Building Inspection Results

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MAPLEWOOD NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  40 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MAPLEWOOD NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 18, 2024, at Maplewood Nursing And Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.





 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 033002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 18, 2024, it was determined that Maplewood Nursing And Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).
This is a four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments, affecting one of four emergency exits.

Findings include:

Observation on January 18, 2024, at 11:20 a.m., revealed, the outside stair tower #1 emergency exit, the egress path was obstructed by snow and ice 2-days post snow event.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the obstructions in the means of egress.




 Plan of Correction - To be completed: 03/01/2024

1.Stair tower emergency exit is now free of snow of ice and snow policy was updated
2.Designee will audit emergency exits are clear for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to ensure Exit Discharges were arranged to provide a level hard-packed walking surface, affecting one of four exit discharges.

Findings include:

Observation on January 18, 2024, at 11:15 a.m., revealed the first floor stair tower #2 emergency exit walking surface traversed through a lawn on the path to the public way. The path was snow/ice covered at time of survey.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the exit discharge conditions.





 Plan of Correction - To be completed: 03/01/2024

1. Time-Limited Waiver requested to add walkway to the public path from emergency exit
2. Designee will audit stair tower #2 emergency exit weekly for four weeks and monthly until completion of the path. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected and serviced at required intervals, affecting one of five levels.

Findings include:

Document review on January 18, 2024, at 9:30 a.m., revealed the facility could not produce documentation showing the following kitchen components had been serviced as required:

a. 2- semi-annual kitchen suppression system inspections.
b. 1- semi-annual kitchen hood cleaning 2023.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 03/01/2024

1. facility has documentation that the kitchen suppression system was inspected and serviced at required intervals.
2. Designee will audit monthly for three months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barrier walls, affecting three of five levels.

Findings include:

Observations on January 18, 2024, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 10:40 a.m., on the fourth floor, above smoke doors to by room 411, around fiber optic bundle.
b. 11:30 a.m., on the third floor, above smoke doors by room 312, around data wires.
c. 11:40 a.m., on the second floor above smoke doors by 211, around fiber optic bundle.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the penetrations.




 Plan of Correction - To be completed: 03/01/2024

1. smoke barriers are now sealed with firestop product number W-L-1478
o Fourth floor, above smoke doors by room 411 around fiber optic bundle
o Third floor above smoke doors by room 312 around data wires
o Second floor above smoke doors by 211 around fiber optic bundle
2. Designee will audit mentioned smoke barriers weekly for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of five levels.

Findings include:

Observation on January 18, 2024, at 11:10 a.m., revealed, in the second floor pantry, a non-GFCI outlet within six feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within six ft of the outside edge of the sink.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the missing GFCI outlet.





 Plan of Correction - To be completed: 03/01/2024

1. second floor pantry now has non-GFCI outlet
2. Designee will audit GFCI outlet in second floor pantry monthly for three months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of chutes and discharge rooms, affecting one of five levels.

Findings include:

Observation on January 18, 2024, at 11:05 a.m., revealed the second floor linen chute door failed to close and latch when tested.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the chute door deficiency.




 Plan of Correction - To be completed: 03/01/2024

1. Second floor linen chute now latches
2. Designee will audit second floor linen chute latch weekly for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to perform four of twelve required fire drills.

Findings include:

Document review on January 18, 2024, at 9:30 a.m., revealed the facility could not provide documentation that a fire drill was conducted for the following:

a. First quarter, Third shift.
b. Second quarter, First shift.
c. Third quarter, Second shift.
d. Fourth quarter, Second shift.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 03/01/2024

1. no retroactive action, facility will complete fire drills as required
Maintenance department will be educated on the requirement and timing of fire drills
2. Designee will audit fire drills completion monthly for three months

NFPA 101 STANDARD Smoking Regulations:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain designated smoking areas, affecting one of one designated smoking location.

Findings include:

Observation on January 18, 2024, at 11:30 a.m., revealed, the designated smoking area had numerous cigarette butts strewn on the wooden deck and the ground adjacent to the designated smoking area.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the smoking area condition.




 Plan of Correction - To be completed: 03/01/2024

1. The deck and ground adjacent to the designated smoking areas are now clear of cigarette butts
2. Designee will audit deck and adjacent areas are clean of cigarette butts weekly for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of five levels.

Findings include:

Observation on January 18, 2024, at 10:45 a.m., revealed, in social services office, an extension cord with an adapter and an outlet multiplier was powering a microwave and a refrigerator.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the unauthorized electrical devices.





 Plan of Correction - To be completed: 03/01/2024

1. Microwave and refrigerator are now plugged directly in wall outlet
2. Designee will audit weekly microwave and refrigerator are plugged directly to the wall weekly for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of five levels.

Findings include:

Observation on January 18, 2024, at 11:20 a.m., revealed an unsecured oxygen cylinder, in the second floor Nurses office.

Exit Interview with the Maintenance Director and Regional Maintenance Director on January 18, 2024, at 12:00 p.m., confirmed the unsecured oxygen cylinder.




 Plan of Correction - To be completed: 03/01/2024

1. Oxygen cylinders are now secure in appropriate holders
2. Designee will audit second floor oxygen cylinders for appropriate storage weekly for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.


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