Pennsylvania Department of Health
MAPLE HEIGHTS HEALTH & REHAB CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MAPLE HEIGHTS HEALTH & REHAB 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 February 14 and 15, 2024, it was determined that Maple Heights Health and Rehab Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:

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.

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.

*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:
Name: - Component: -- - Tag: 0039
Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to meet the Emergency Preparedness Testing Requirements of the emergency plan.

Findings include:

1. Interview and documentation review of the facility EP plan on February 15, 2023, at 9:50 a.m., revealed the facility failed to meet the annual requirements of section (i) full-scale exercise community-based or an Individual facility-based exercise.

Interview with the Facility Administrator and Maintenance Director on February 15, 2024, at 11:30 a.m. confirmed the listed EP plan training/testing deficiency.

Plan of Correction - To be completed: 03/07/2024

1. Maple Heights will conduct an individual facility based exercise by March 20th 2024.
2. Maintenance director or designee will ensure exercises are scheduled annually.

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

Facility ID# 030202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 14 and 15, 2024, it was determined that Maple Heights Health and Rehab Center 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 483.90(a).

This is a five-story, Type II (222), fire-resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the healthcare occupancy from other occupancies in one instance, affecting the entire facility.

Findings include:

1. Observation on February 14, 2024, at 11:05 a.m., revealed the occupancy separation door to the entrance of Village and Maple on the fifth floor was unable to close and latch in its frame when tested.

Interview with the Facility Administrator and the Maintenance Director on February 15, 2024, at 11:30 a.m., confirmed the listed occupancy separation deficiency.

Plan of Correction - To be completed: 03/07/2024

1. Cambria Glass replaced the entire door, frame, and fire rated hardware to allow door to function properly.
2. A preventive maintenance work order is in place to inspect fire doors annually.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

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 three instances, affecting one of twenty-three smoke compartments.

Findings include:

1. Observation on February 14, 2024, revealed the facility failed to maintain the required one-hour fire rating in the following hazardous area enclosure locations:

a) 12:48 p.m., the doors to the PLS washroom would not self-close and latch in their frame when tested;
b) 12:50 p.m., the arm for the self-closer device was unhooked from the door to the PLS clean holding room G-182;
c) 12:52 p.m., the doors to the PLS sorting room doors by the loading dock would not self-close and latch in their frame when tested.

Interview with the Facility Administrator and the Maintenance Director on February 15, 2024, at 11:30 a.m., confirmed the listed hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 03/07/2024

1. Maintenance staff corrected the self-closure by reattaching the arm at the time of the survey. Cambria Glass to repair the two PLS doors that would not latch and
2. A preventive maintenance work order is in place to inspect fire doors annually.

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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in four instances, affecting four of twenty-three smoke compartments.

Findings include:

1. Observation on February 14, 2024, revealed the following automatic sprinkler deficiencies:

a) 10:09 a.m., the facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic sprinkler system. There were unsealed penetrations in the fourth-floor med room ceiling above the electrical cabinet;
b) 10:30 a.m., the facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic sprinkler system. There was a missing ceiling tile in the third-floor north shower room;
c) 11:50 a.m., the facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic sprinkler system. There were unsealed penetrations in the first-floor med room ceiling above the electrical cabinet;
d) 12:37 p.m., the facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic sprinkler system. The sprinkler head escutcheon in the ground floor south hallway outside of the IT room was unable to touch the ceiling and create a smoke-resistant seal.

Interview with the Facility Administrator and the Maintenance Director on February 15, 2024, at 11:30 a.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 03/07/2024

1. Maintenance staff corrected all four instances affecting 4/23 smoke compartments. Maintenance staff corrected unsealed penetrations by sealing with fire caulk. Ceiling tile deficiency was corrected upon observation by replacing ceiling tile. The Sprinkler head escutcheon was corrected upon observation by pushing back in place at the time of the survey.
2. Maintenance Director or designee will do biweekly audits for two months on unsealed ceiling penetrations, missing ceiling and sprinkler head escutcheon.

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 three instances, affecting five of twenty-three smoke compartments.

Findings include:

1. Observation on February 14, 2024, revealed the following smoke barrier wall deficiencies:

a) 10:16 a.m., inspection above the ceiling at the fourth-floor south wing smoke barrier doors revealed there were unsealed data wires in a conduit passing through the smoke barrier wall;
b) 11:48 a.m., inspection above the ceiling at the first-floor northwest wing smoke barrier doors revealed there were unsealed data wires in a conduit passing through the smoke barrier wall;
c) 12:36 p.m., inspection above the ceiling at the first-floor east wing smoke barrier doors revealed there were unsealed data wires in a conduit passing through the smoke barrier wall.

Interview with the Facility Administrator and the Maintenance Director on February 15, 2024, at 11:30 a.m., confirmed the listed smoke barrier wall deficiencies.

Plan of Correction - To be completed: 03/07/2024

1. Maintenance staff corrected all deficiencies upon observation by sealing all penetrations with fire caulk.
2. Maintenance Director or designee will audit penetrations every two weeks for two months.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, affecting one of twenty-three smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101.

Findings include:

1. Observation on February 14, 2024, at 10:19 a.m., revealed an unsecured electrical box behind the whirlpool tub in the fourth-floor shower room leaving the attached MC cable pulled from the wall.

Interview with the Facility Administrator and the Maintenance Director on February 15, 2024, at 11:30 a.m., confirmed the listed electrical wiring deficiency.

Plan of Correction - To be completed: 03/07/2024

1. Maintenance staff immediately corrected the deficiency at the time of observation. Maintenance reattached electrical MC cable box to wall.
2. Maintenance Director added line item to monthly checklist to inspect electrical boxes to ensure they are secure.

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 two instances, affecting two of twenty-three smoke compartments, per NFPA 99 2012 Edition, Chapter 10.1.1

Findings include:

1. Observation on February 14, 2023, revealed access to the following electrical panels was blocked by storage:

a) 12:34 p.m., in the south-east wing janitor room on the first floor;
b) 12:41 p.m., in the Senior Life server/storage room.

Interview with the Facility Administrator and the Maintenance Director on February 15, 2024, at 11:30 a.m., confirmed the listed electrical equipment deficiencies.

Plan of Correction - To be completed: 03/07/2024

1. Maintenance staff corrected both deficiencies upon observation. Removed storage shelf from janitor's closet and removed wheelchairs from server/storage room.
2. Maintenance Director educated staff on proper storage around electrical panels. Maintenance will audit storerooms once a week for one month.

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000

Facility ID# 030202
Component 03
LPN Classroom

Based on a Medicare/Medicaid Recertification Survey completed on February 14 and 15, 2024, it was determined that Maple Heights Health and Rehab Center 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 483.90(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 Hazardous Areas - Enclosure:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0321

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

Findings include:

1. Observation on February 14, 2024, revealed the facility failed to maintain the required one-hour fire rating in the following hazardous area enclosure locations:

a) 1:03 p.m., the rear door to the housekeeping office/storage room would not self-close and latch in its frame when tested;
b) 1:10 a.m., there was a large section of ceiling missing in elevator equipment room number four.

Interview with the Facility Administrator and the Maintenance Director on February 15, 2024, at 11:30 a.m., confirmed the listed hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 03/07/2024

1. The rear door latch to the housekeeping office/storage room was fixed and the ceiling in the elevator equipment room was fixed.
2.The ceiling tiles and door latch will be monitored by the maintenance director

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one of four smoke compartments.

Findings include:

1. Observation on February 14, 2024, at 11:10 a.m., revealed there was an electrical receptacle within six feet of a sink, in the kitchen behind the meat slicer, that was not GFCI-protected.

Interview with the Facility Administrator and the Maintenance Director on February 15, 2024, at 11:30 a.m., confirmed the listed electrical receptacle deficiency.

Plan of Correction - To be completed: 03/07/2024

1. Maintenance staff installed GFCI receptacle in the kitchen behind the meat slicer.
2. Preventative Maintenance is in place to inspect GFCI receptacles Quarterly.

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