Pennsylvania Department of Health
 MARYWOOD HEIGHTS
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MARYWOOD HEIGHTS
Inspection Results For:

There are  44 surveys for this facility. Please select a date to view the survey results.

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MARYWOOD HEIGHTS - 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, 2025, it was determined that Marywood Heights had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.





 Plan of Correction:


403.748(b)(8), 416.54(b)(6), 418.113(b)(6)(C)(iv), 441.184(b)(8), 482.15(b)(8), 483.475(b)(8), 483.73(b)(8), 485.542(b)(7), 485.625(b)(8), 485.920(b)(7), 494.62(b)(7) STANDARD Roles Under a Waiver Declared by Secretary: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.
§403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.
Observations:
Name: - Component: -- - Tag: 0026

Based on documentation review and interview, it was determined the facility failed to maintain the Emergency Response Plan for the entire facility.

Findings include:

1. Observation on May 19, 2025, at 1:00 pm, revealed the facility lacked the 1135 Waivers that may be issued by US Health and Human Services Secretary, in the facility Emergency Response Plan.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the emergency preparedness deficiency.











 Plan of Correction - To be completed: 05/23/2025

Facility has implemented the appropriate documentation for the 1135 waiver.
403.748(c)(3), 416.54(c)(3), 418.113(c)(3), 441.184(c)(3), 482.15(c)(3), 483.475(c)(3), 483.73(c)(3), 484.102(c)(3), 485.542(c)(3), 485.625(c)(3), 485.68(c)(3), 485.727(c)(3), 485.920(c)(3), 486.360(c)(3), 491.12(c)(3), 494.62(c)(3) STANDARD Primary/Alternate Means for Communication: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.
§403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Observations:
Name: - Component: -- - Tag: 0032

Based on documentation review and interview, it was determined the facility failed to maintain the Emergency Preparedness Plan for the entire facility.

Findings include:

1. Observation on May 19, 2025, at 12:55 pm, revealed the facility lacked a Delegation of Authority succession plan, current staff roster, and contact information in the Emergency Preparedness Plan.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the emergency preparedness deficiency.







 Plan of Correction - To be completed: 05/23/2025

The Delegation of Authority and staff roster, along with the contact information, has been added to the Emergency preparedness plan.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 860302
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on May 19, 2025, it was determined that Marywood Heights was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a three story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements on three of three floors.

Findings include:

1. Observation on May 19, 2025, at 11:30 am, revealed the facility exceeded the maximum allowable story height for this type of construction.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the facility exceeded the maximum allowable story height.








 Plan of Correction - To be completed: 05/23/2025

In July 2019, the facility was reclassified as a three story structure with an attic space and basement. The facility is requesting a time limited waiver to have a new FSES completed.
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 ensure that exit access corridors were maintained clear and unobstructed, affecting one of three floors.

Findings include:

1. Observation on May 19, 2025, at 11:20 am, Basement Level, revealed items being stored on both sides of the exit corridor, items including a recliner, decorations.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed this storage of these items.










 Plan of Correction - To be completed: 06/01/2025

Items being stored on both sides of the corridor on the Basement Level were removed. Director of Maintenance or designee will conduct audits monthly times 2 months to ensure that items are being stored correctly.


NFPA 101 STANDARD Doors with Self-Closing Devices: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.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices, affecting two of three floors.

Findings include:

1. Observation on May 19, 2025, between 11:53 am, and 12:14 pm, revealed the following:

a. At 11:53 am, 3rd floor, Supply room (small), door failed to positive latch into frame when tested.
b. At 12:05 pm, 2nd floor, Linen room, door failed to positive latch into frame when tested, near dining room.
c. At 12:14 pm, 2nd floor, Clean Utility room, door failed to positive latch into frame when tested.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the self-closure door deficiency.



 Plan of Correction - To be completed: 05/23/2025

The following doors were corrected and latch properly: 3rd floor supply room, 2nd floor linen, clean utility room 2nd floor. Director of Maintenance or designee will conduct random audits monthly times 2 months to ensure doors are latching properly.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain exit components in one location, affecting three of three floors.

Findings include:

1. Observation on May 19, 2025, at 11:20 am, Basement level, revealed the stair tower enclosure exit door discharge hardware was missing a screw, near Laundry.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the stair tower enclosure deficiency.









 Plan of Correction - To be completed: 05/23/2025

The hardware for the Basement level stair tower enclosure was corrected. Director of Maintenance or designee will conduct random audits monthly times 2 months to ensure hardware on doors is in place.
NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain one exit sign, affecting one of six smoke compartments.

Findings include:

1. Observation on May 19, 2025, at 11:41 am, 3rd floor, revealed the the exit sign, located in the corridor near Resident Room 370, was not secured in the base.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the exit sign was not secured.











 Plan of Correction - To be completed: 05/23/2025

The exit sign for the 3rd floor corridor neat resident room 370 was ordered and will be installed upon delivery. Director of Maintenance or designee will conduct random audits monthly times 2 months to ensure exit signs are functioning properly.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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 two hazardous area enclosures, affecting one of three floors.

Findings include:

1. Observation on May 19, 2025, between 11:10 am, and 11:12 am, revealed the following:

a. At 11:10 am, Basement Level, maintenance shop door 018, failed to postive latch into frame when tested.
b. At 11:12 am, Basement Level, storage room door 016, positive latching hardware had been removed.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the hazardous area enclosure deficiencies.









 Plan of Correction - To be completed: 05/23/2025

The following doors have been corrected and latch properly: Maintenance shop door and Basement storage room. Director of Maintenance or designee will conduct random audits monthly times 2 months to ensure doors are latching properly.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review, observations, and interview, it was determined the facility failed to maintain the sprinkler system, affecting one of three floors.

Findings include:

1.Observation on May 19, 2025, between 11:40 am, and 11:45 am, revealed the following:

a. At 11:40 am, 3rd floor, Corridor near Resident Room 319 was missing 2 escutcheons.
b. At 11:45 am, 3rd floor, Lounge was missing 2 escutcheons.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the missing escutcheons.




 Plan of Correction - To be completed: 05/23/2025

JW Sprinkler has been contacted to come and replace missing escutcheons in corridor near room 319 and 3rd floor lounge. Director of Maintenance or designee will conduct random audits monthly times 2 months to ensure escutcheons are properly in place.
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 smoke barrier walls in one location, on one of three floors.

Findings include:

1. Observation on May 19, 2025, at 12:11 pm, 2nd floor, revealed a unsealed penetration around an MC cable above the ceiling to the right of the doors, near Resident Room 267.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the unsealed penetration.




 Plan of Correction - To be completed: 05/23/2025

Unsealed penetration around MC cable above ceiling to right of doors near resident room 267 has been corrected. Director of Maintenance or designee will conduct random audits monthly times 2 months to ensure areas are sealed with no penetration.
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 fire drills on a random basis.

Findings include:

1.Observation on May 19, 2025, at 10:40 am, revealed that 3 of 4 required quarterly fire drills for 3rd shift were conducted within the same hour. (0500, 0500, 0540).

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the fire drills were not conducted at random times.




 Plan of Correction - To be completed: 05/23/2025

Facility is not able to retroactively correct the deficient practice. Fire drills on the third shift will be conducted at random times moving forward. Director of Maintenance or designee will conduct random audits monthly times 2 months to ensure fire drills are within random times on third shift.
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, the facility failed to properly secure oxygen cylinders, on two of three floors

Findings include:

1.Observation on May 19, 2025, between 11:48 am, and 12:16 pm, revealed the following:

a. At 11:48 am, 3rd floor, Oxygen storage room, had an unsecured "E" oxygen cylinder being stored with the room.
b. At 12:16 pm, 2nd floor, Oxygen storage room, had an unsecured "E" oxygen cylinder being stored with the room.

Exit interview with the Facility Administrator and Facilities Manager on May 19, 2025, at 1:15 pm, confirmed the oxygen cylinders were not secured from falling over.




 Plan of Correction - To be completed: 05/23/2025

Unsecured E oxygen cylinders have been secured in 2nd and 3rd floor storage rooms. Director of Maintenance or designee will conduct random audits monthly times 2 months to ensure oxygen cylinders are stored appropriately.

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