Pennsylvania Department of Health
CONTINUING CARE AT MARIS GROVE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CONTINUING CARE AT MARIS GROVE - 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 February 24, 2026, at Continuing Care At Maris Grove, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0000
Facility ID# 21670201Component 01Based on a Medicare/Medicaid Recertification Survey completed on February 24, 2026, it was determined that Continuing Care At Maris Grove 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 three-story, Type II (222), fire resistive building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire facility. Findings include: Document review on February 24, 2026, at 8:00 am, revealed the facility could not provide documentation showing smoke detector sensitivity was conducted within the previous twenty-four month.Exit interview with the Administrator and the Maintenance Director on February 24, 2026, at 10:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 03/18/2026

0345- Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire facility. Findings include: Document review on February 24, 2026, at 8:00 am, revealed the facility could not provide documentation showing smoke detector sensitivity was conducted within the previous twenty-four months. Exit interview with the Administrator and the Maintenance Director on February 24, 2026, at 10:30 am, confirmed the lack of documentation.

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

No residents were identified as being directly affected by the deficient practice. The facility immediately contacted fire alarm vendor to complete and provide documentation of the required testing. ESS testing is scheduled for March 18, 2026. Documentation of required testing is forthcoming.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

The facility conducted a review of all fire alarm inspection, testing, and maintenance records to ensure compliance with NFPA requirements. Any missing documentation will be obtained from the vendor and filed in the Life Safety documentation binder.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

The Maintenance Supervisor, Security Manager and designee will be re-educated by the Director of Continuing Care/Licensed Nursing Home Administrator or designee regarding the NFPA 70 and NFPA72 National Fire Alarm and Signaling Code specifically that the facility must conduct and readily maintain copies of smoke detector sensitivity.

How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?

The Maintenance Supervisor or Designee will review fire alarm testing documentation annually to ensure ongoing compliance. Results will be reviewed through the facility's QAPI process to ensure the deficient practice does not recur.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility. Findings include: Document review on February 24, 2026, at 8:00 am, revealed the facility could not provide documentation showing an internal valve and pipe inspection was performed within the past five years.Exit interview with the Administrator and the Maintenance Director on February 24, 2026, at 10:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 04/15/2026

0353- Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility.
Findings include: Document review on February 24, 2026, at 8:00 am, revealed the facility could not provide documentation showing an internal valve and pipe inspection was performed within the past five years. Exit interview with the Administrator and the Maintenance Director on February 24, 2026, at 10:30 am, confirmed the lack of documentation.

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

No residents were identified as being directly affected by the deficient practice. The facility immediately contacted BFPE, the contracted vendor, to schedule the required sprinkler system testing. Testing is scheduled for the week of April 13, 2026. Documentation of required testing is forthcoming.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

The facility conducted a review of all sprinkler system inspection, testing, and maintenance documentation to ensure a plan to meet compliance with NFPA 25 requirements. Any missing documentation will be obtained from the vendor and placed in the facility's Life Safety documentation binder.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

The Maintenance Supervisor, Security Manager and Designee will be re-educated on NFPA-25, specifically the standards for inspection Water-based Fire Protection Systems.

How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?

The Maintenance Supervisor or Designee will review Life Safety documentation annually to ensure all required sprinkler system inspections and testing are current. Compliance will also be reviewed through the facility's QAPI process to ensure the deficient practice does not recur.

NFPA 101 STANDARD Evacuation and Relocation Plan:

Evacuation and Relocation Plan
There is a written plan for the protection of all patients and for their evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2.
18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0711 Based on document review and interview, it was determined the facility failed to create and evacuation and relocation plan, affecting the entire facility. Findings include: Document review on February 24, 2026, at 8:00 am, revealed the facility failed to provide a fire alarm evacuation and relocation plan.Exit interview with the Administrator and the Maintenance Director on February 24, 2026, at 10:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 03/18/2026

0711- Based on document review and interview, it was determined the facility failed to create and evacuation and relocation plan, affecting the entire facility. Findings include: Document review on February 24, 2026, at 8:00 am, revealed the facility failed to provide a fire alarm evacuation and relocation plan. Exit interview with the Administrator and the Maintenance Director on February 24, 2026, at 10:30 am, confirmed the lack of documentation.

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

No residents were identified as being directly affected by the deficient practice. The facility maintains a fire alarm evaluation and relocation plan. Following the survey, the plan was reviewed and made readily accessible. The documentation is now maintained in the Emergency Preparedness compliance binder.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

The facility conducted a review of emergency preparedness and fire evacuation documentation to ensure the evacuation and relocation plan is current and readily available.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

The evacuation and relocation plan will be maintained in the facility's Life Safety documentation binder and emergency preparedness records to ensure it is readily accessible for review. The Continuing Care Director has reviewed Life Safety documentation requirements to ensure all required documentation is available during inspections.

How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?

The Continuing Care Director or Designee will review the Emergency Preparedness Plan annually to ensure the evacuation and relocation plan and other required Life Safety records remain current and readily available. Compliance will be reviewed through the facility's QAPI process to ensure the deficient practice does not recur.

Initial comments:Name: ASSISTED LIVING BUILDING - Component: 02 - Tag: 0000
Facility ID# 21670201Component 02Assisted Living BuildingBased on a Medicare/Medicaid Recertification Survey completed on February 24, 2026, at Continuing Care At Maris Grove, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for a New 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 three-story, Type II (111), protected noncombustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

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