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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 39 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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 27, 2024, 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# 21670201
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, 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 Cooking Facilities:

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.

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: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0324

Based on documentation review and interview, it was determined the facility failed to perform three of twelve monthly kitchen fire suppression system inspections, affecting one of eleven smoke compartments.

Findings include:

Document review on February 27, 2024, at 11:15 a.m., revealed the monthly inspections for the kitchen fire suppression system were not documented in November, December, or January.

Interview with the Facility Administrator and Maintenance Director on February 27, 2024, at 2:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 04/02/2024

1. The Monthly inspection reports for the kitchen suppression system are current.
2. The Maintenance Director/designee will audit current monthly maintenance inspection tasks for compliance.
3. The Maintenance Supervisor/designee will educate the maintenance staff on K0324 and the Monthly Kitchen Suppression inspection of the system.
4. The Maintenance Supervisor /designee will audit the documentation for the Kitchen Suppression system inspection reports monthly, X2 months, and report findings to the QAPI Committee for review.

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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of eleven smoke compartments.

Findings include:

Observation on February 27, 2024, at 11:25 a.m., revealed two sprinkler heads in the kitchen walk-in cooler were loaded with dust and debris.

Interview with the Facility Administrator and Maintenance Director on February 27, 2024, at 2:00 p.m., confirmed the sprinkler heads were loaded with dust and debris.

Plan of Correction - To be completed: 04/02/2024

1. The two sprinkler heads in the kitchen walk-in cooler were cleaned of dust and debris.
2. An Inspection of all sprinkler heads in the kitchen was conducted to ensure compliance. No other sprinkler heads were covered in dust and debris.
3. The Maintenance Supervisor/designee will educate the maintenance staff on K0353 and the importance of proper maintenance of all sprinkler heads
4. The Maintenance Supervisor /designee will inspect the Kitchen sprinkler heads monthly, X 2 months, and report findings to the QAPI Committee for review.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in two instances, affecting two of eleven smoke compartments.

Findings include:

Observation on February 27, 2024, at 11:25 a.m., revealed the following electrical equipment and wiring deficiencies:

a) 11:40 a.m., a microwave was plugged into a plug multiplier in the housekeeping supervisor's office in the basement;
b) 12:35 p.m., in the Quiet Room (Faith's Office) on the first floor, there was a coffee maker plugged into an extension cord and a refrigerator and microwave plugged into power strips that were plugged into another power strip.

Interview with the Facility Administrator and Maintenance Director on February 27, 2024, at 2:00 p.m., confirmed the misuse of electrical equipment and power cords.

Plan of Correction - To be completed: 04/02/2024

1. The plug multiplier in the housekeeping supervisor's office was removed. The microwave plugs directly into an outlet at this time. The Extension cord and power strips were removed from the Quiet room. The refrigerator and microwave plug directly into an outlet at this time.
2. An inspections of the entire facility was conducted to ensure that no plug multipliers, extension cords or power strips are being utilized.
3. The Maintenance Supervisor/designee will educate the staff that use those offices on K0920.
4. The Maintenance Supervisor /designee will report the inspection results monthly, X 2 months, to the QAPI Committee for review.

Initial comments:Name: ASSISTED LIVING BUILDING - Component: 02 - Tag: 0000

Facility ID# 21670201
Component 02
Assisted Living Building

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, 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:

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement