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

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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 May 19, 2026, at Maple Winds Healthcare and Rehabilitation Center LLC, 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# 09750201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 19, 2026, 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 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 documentation review and interview, it was determined the facility failed to perform three of twelve required fire drills.

Findings include:

1. Review of documentation on May 19, 2026, at 11:30 a.m., revealed the facility lacked documentation for first and second shift fire drills in the second quarter, and a first shift drill in the fourth quarter.

Interview with the Facility Administrator and the Maintenance Director on May 19, 2026, at 1:30 p.m., confirmed the missing fire drill documentation.

Plan of Correction - To be completed: 06/30/2026

Noted facility's failure to perform three of twelve fire drills. Noted not completed-second quarter, first and second shift fire drills and fourth quarter, first shift drill. The fourth quarter, first shift drill was completed December 30, 2025-see attached. The drills from the second quarter, first and second shift were completed, however documentation was not available. Prior to October 2025, paper records were kept. The previous survey was completed in July 2025. The Maintenance Director destroyed previous records to maintain 12-month survey cycle. All drills after October 2025 are logged into the Sequra system and digitally stored.

Moving forward, all drills will be electronically available from October 2025 ongoing. The Maintenance Director will maintain digital records moving forward for all 4 quarters between surveys.

Education provided to the Maintenance Director for record keeping of all fire drills by Nursing Home Administrator.

All fire drills for all quarters on all shifts will be audited by Maintenance Director monthly x 3 months and reviewed in Quarterly Quality Assurance Process Improvement Meetings.

Correction of process will be completed by June 30, 2026.

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