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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 33 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:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on June 10, 2024, it was determined that ha Maple Winds Healthcare and Rehabilitation Center, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:

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.

§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..

Observations:
Name: - Component: -- - Tag: 0041
Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in four instances, affecting the entire facility.

Findings include:

1. Review of documentation on June 10, 2024, at 11:30 a.m., revealed the following emergency generator deficiencies:

a) the facility lacked documentation for a four-hour run to be performed every three years for the emergency generator. Documentation for the most recent four-hour run was from February 24, 2021;
b) the facility lacked annual maintenance and testing documentation and annual load bank testing for the emergency generator. Documentation for the most recent annual testing and annual load bank testing was from March 13, 2023;
c) the facility lacked documentation to confirm if the emergency generator met the requirements for no evidence of wet stacking. Documentation for the most recent annual wet stacking testing was from March 13, 2023;
d) the facility failed to document the required monthly testing/function of the automatic transfer switch, for five of the past twelve months that a delay of not more than ten seconds shall be permitted to emergency power. Testing shall be per NFPA 110, 8.4.6. and NFPA 101 7.9.1.3.

Interview with the Facility Administrator and the Maintenance Director on June 10, 2024, at 1:30 p.m., confirmed the listed emergency generator testing deficiencies.

Plan of Correction - To be completed: 07/16/2024

a.) Four-hour run emergency generator test will be completed and documented

b) Annual maintenance and testing and annual load bank testing for the emergency generator has been completed and documented.by Cummings Deisel contractors.

c) Annual wet stacking emergency generator testing was completed and documented by Cummings diesel Contractors.

d) Monthly testing/function of the automatic transfer switch testing has been completed with results indicating a delay of not more than ten seconds to emergency power.

e.) Maintenance staff are aware of the importance of the monthly and yearly required testing be completed and documented within the required time frame..

f) Life safety requirements will be discussed with the Maintenance Director at the monthly Quality Assurance meeting to ensure that requirements are done in the required time frame.

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

Facility ID# 09750201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 10, 2024, it was determined that Maple Winds Healthcare and Rehabilitation LLC was not in compliance with the following requirements of the Life Safety Code for an existing healthcare occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Egress Doors:

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.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING - 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain exit access in two instances, affecting exiting from two of five smoke compartments.

Findings include:

1) Observation on June 10, 2024, revealed the following exit access deficiencies:

a) 10:44 a.m., the A-wing exit door had labeling to communicate that the door was equipped with a fifteen-second delay egress, but the door would not release when tested;
b) 10:48 a.m., the C-wing exit door had labeling to communicate that the door was equipped with a fifteen-second delay egress, but the door would not release when tested.

Interview with the Facility Administrator and the Maintenance Director on June 10, 2024, at 1:30 p.m., confirmed the listed exit access deficiencies.

Plan of Correction - To be completed: 07/16/2024

The A-wing exit door does not have delayed egress.The signage reads door will alarm when opened not open after 15 seconds.

The C-wing exit door does not have delayed egress.
The signage reads door will alarm when opened not open after 15 seconds.

The doors are keypad operated and disengage when the fire panel is activated.

The locks are fail safe magnetic locks.

The building is fully sprinklered and the locks are disengaged when fire panel is activated.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING - 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in two instances, affecting two of five smoke compartments.

Findings include:

1. Observation on June 10, 2024, revealed the facility failed to maintain the required one-hour fire rating in the following hazardous area enclosure locations:

a) 10:28 a.m., there was an unsealed copper pipe penetrating the wall of the E-wing electrical room above the dish network server;
b) 10:38 a.m., there was a large unsealed hole in the wall of the B-wing electrical/mechanical room by the pump control panel.

Interview with the Facility Administrator and the Maintenance Director on June 10, 2024, at 1:30 p.m., confirmed the listed hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 07/16/2024

The copper pipe penetrating the wall of the E-wing electrical room above the dish network server has been sealed with an approved through stop penetration system (3M Fire Barrier Sealant) to maintain the integrity of the wall assembly

Large hole in the wall of the B-wing electrical/mechanical room by the pump control panel has been sealed, maintaining the required one-hour fire rating in this hazardous area enclosure location.

Areas throughout the building were reviewed for other concerns and repaired as applicable.

Maintenance staff are aware of the need for monthly checks for smoke and fire barrier walls as well as new areas of noted concern and corrective action to take place as applicable.

The Maintenance Director/designee will complete a monthly check of smoke and fire barrier walls and ceilings as part of preventative maintenance. And to ensure compliance, will check monthly for three months. Findings will be reviewed at monthly Quality Assurance meetings for compliance, improvement and need for continued auditing

NFPA 101 STANDARD Cooking Facilities:

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 documentation review and interview, it was determined the facility failed to maintain the kitchen hood in two instances, affecting one of five smoke compartments.

Findings include:

1. Document review on June 10, 2024, at 11:30 a.m., revealed the following kitchen hood deficiencies:

a) The facility failed to perform one of two required semi-annual inspections of the kitchen hood suppression system. The most recent kitchen hood suppression system inspection was completed on November 11, 2023;
b) The facility failed to perform one of two required semi-annual kitchen hood cleanings. The most recent kitchen hood cleaning was completed on November 11, 2023.

Interview with the Facility Administrator and the Maintenance Director on June 10, 2024, at 1:30 p.m., confirmed the listed kitchen hood deficiencies.

Plan of Correction - To be completed: 07/16/2024

The semi-annual inspection of the kitchen hood suppression system was completed and documented.

The required semi-annual kitchen hood cleaning was completed and documented.

Maintenance staff are aware of the importance of the annually required testing be completed within the required time frame..

Life safety requirements will be discussed with the Maintenance Director at the monthly Quality Assurance meeting.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING - 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined that the facility failed to maintain annual portable fire extinguishers in three instances, affecting three of five smoke compartments.

Findings include:

1. Observation on June 10, 2024, at 11:00 a.m., revealed the following portable fire extinguisher deficiencies:

a) 9:48 a.m., the portable fire extinguisher in the maintenance shop/office had not been visually inspected for five of the past eleven months;
b) 10:18 a.m., the laundry room was not equipped with a portable fire extinguisher per NFPA 10 2010 Edition, Chapter 5.4.2;
c) 10:31 a.m., the portable fire extinguisher by the PC entrance door had not been visually inspected for five of the past eleven months.

Interview with the Facility Administrator and the Maintenance Director on June 10, 2024, at 1:30 p.m., confirmed the listed portable fire extinguisher deficiencies.

Plan of Correction - To be completed: 07/16/2024

The portable fire extinguisher in the maintenance shop/office had been visually inspected and documented.

The laundry room has been equipped with a portable fire extinguisher.

The portable fire extinguisher by the PC entrance door has been visually inspected.

Areas throughout the building were reviewed for other concerns and inspected where applicable.

Maintenance staff are aware of the need for monthly checks of fire extinguishers as required.

This will be reviewed at the monthly Quality Assurance meetings.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 smoke barrier walls in one instance, affecting two of five smoke compartments.

Findings include:

1. Observation above the ceiling on June 10, 2024, at 10:23 a.m., at the E-wing smoke barrier doors revealed multiple unsealed data wires in a conduit passing through the smoke barrier wall (PC side of the smoke barrier wall).

Interview with the Facility Administrator and the Maintenance Director on June 10, 2023, at 1:30 p.m., confirmed the listed smoke barrier wall deficiency.

Plan of Correction - To be completed: 07/16/2024

Multiple data wires in the conduit passing through the smoke barrier wall (PC side of the smoke barrier wall) above the ceiling at the E-wing smoke barrier doors were sealed with an approved through stop penetration system (3M Fire Barrier Sealant) to maintain the integrity of the wall assembly

Areas throughout the building were reviewed for other concerns and repaired as applicable.

Maintenance staff are aware of the need for monthly checks for smoke and fire barrier walls as well as new areas of noted concern and corrective action to take place as applicable.

The Maintenance Director/designee will complete a monthly check of smoke and fire barrier walls and ceilings as part of preventative maintenance. And to ensure compliance, will check monthly for three months.

Findings will be reviewed at monthly Quality Assurance meetings for compliance, improvement and need for continued auditing

NFPA 101 STANDARD Fire Drills:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

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 documentation review and interview, it was determined the facility failed to perform one of 12 required fire drills affecting the entire facility.

Findings include:

1. Review of documentation on June 10, 2024, at 11:30 a.m., revealed the facility lacked documentation for a second-quarter fire drill for the third shift.

Interview with the Facility Administrator and the Maintenance Director on June 10, 2024, at 1:30 p.m., confirmed the missing fire drill deficiency.

Plan of Correction - To be completed: 07/16/2024

The facility will conduct and document a fire drill for the third shift.

Maintenance staff are aware of the importance of the monthly required testing be completed within the required time frame..

Life safety requirements will be discussed with the Maintenance Director at the monthly Quality Assurance meeting to insure that requirements are done in the required time frame.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING - 01 - Component: 01 - Tag: 0918
Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in four instances, affecting the entire facility.

Findings include:

1. Review of documentation on June 10, 2024, at 11:30 a.m., revealed the following emergency generator deficiencies:

a) the facility lacked documentation for a four-hour run to be performed every three years for the emergency generator. Documentation for the most recent four-hour run was from February 24, 2021;
b) the facility lacked annual maintenance and testing documentation and annual load bank testing for the emergency generator. Documentation for the most recent annual testing and annual load bank testing was from March 13, 2023;
c) the facility lacked documentation to confirm if the emergency generator met the requirements for no evidence of wet stacking. Documentation for the most recent annual wet stacking testing was from March 13, 2023;
d) the facility failed to document the required monthly testing/function of the automatic transfer switch, for five of the past twelve months that a delay of not more than ten seconds shall be permitted to emergency power. Testing shall be per NFPA 110, 8.4.6. and NFPA 101 7.9.1.3.

Interview with the Facility Administrator and the Maintenance Director on June 10, 2024, at 1:30 p.m., confirmed the listed emergency generator testing deficiencies.

Plan of Correction - To be completed: 07/16/2024

Four-hour run emergency generator test will be completed and documented

Annual maintenance and testing and annual load bank testing for the emergency generator has been completed and documented.by Cummings Deisel contractors.

Annual wet stacking emergency generator testing was completed and documented by Cummings diesel Contractors.

Monthly testing/function of the automatic transfer switch testing has been completed with results indicating a delay of not more than ten seconds to emergency power.

Maintenance staff are aware of the importance of the monthly and yearly required testing be completed and documented within the required time frame..

Life safety requirements will be discussed with the Maintenance Director at the monthly Quality Assurance meeting to ensure that requirements are done in the required time frame.

NFPA 101 STANDARD Electrical Equipment - Other:

Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 10 (NFPA 99)

Observations:
Name: MAIN BUILDING - 01 - Component: 01 - Tag: 0919
Based on observation and interview, it was determined the facility failed to maintain electrical equipment in one instance, affecting one of five smoke compartments, per NFPA 99 2012 Edition, Chapter 10.1.1

Findings include:

1. Observation on June 10, 2024, at 9:50 a.m., revealed access to the electrical panels in the Maintenance office/shop was obstructed by miscellaneous storage.

Interview with the Facility Administrator and the Maintenance Director on June 10, 2024, at 1:30 p.m., confirmed the listed electrical equipment deficiency.

Plan of Correction - To be completed: 07/16/2024

Miscellaneous storage obstructing the electrical panels in the Maintenance office/shop has been removed ensuring access to the electrical panels..

Tape will be placed on the floor at 3' from the electric panels to mark area to keep clear.

Areas throughout the building were reviewed for other concerns and repaired as applicable.

The Maintenance Director/designee will complete a check of electric panels throughout the building. And to ensure compliance, will check weekly times three months.
Findings will be reviewed at monthly Quality Assurance Meetings.

Initial comments:Name: MAPLE WINDS CARE CENTER - Component: 02 - Tag: 0000

Facility ID# 09750201
Component 02
B Wing Addition
PC Dining and Office

Based on a Medicare/Medicaid Recertification Survey completed on June 10, 2024, it was determined that Maple Winds Healthcare and Rehabilitation LLC was not in compliance with the following requirements of the Life Safety Code for an existing healthcare occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: MAPLE WINDS CARE CENTER - Component: 02 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in four instances, affecting the entire facility.

Findings include:

1. Review of documentation on June 10, 2024, at 11:30 a.m., revealed the following emergency generator deficiencies:

a) the facility lacked documentation for a four-hour run to be performed every three years for the emergency generator. Documentation for the most recent four-hour run was from February 24, 2021;
b) the facility lacked annual maintenance and testing documentation and annual load bank testing for the emergency generator. Documentation for the most recent annual testing and annual load bank testing was from March 13, 2023;
c) the facility lacked documentation to confirm if the emergency generator met the requirements for no evidence of wet stacking. Documentation for the most recent annual wet stacking testing was from March 13, 2023;
d) the facility failed to document the required monthly testing/function of the automatic transfer switch, for five of the past twelve months that a delay of not more than ten seconds shall be permitted to emergency power. Testing shall be per NFPA 110, 8.4.6. and NFPA 101 7.9.1.3.

Interview with the Facility Administrator and the Maintenance Director on June 10, 2024, at 1:30 p.m., confirmed the listed emergency generator testing deficiencies.

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