Pennsylvania Department of Health
MANCHESTER COMMONS OF PRESBYTERIAN SENIORCARE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MANCHESTER COMMONS OF PRESBYTERIAN SENIORCARE - 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 August 8, 2024, at Manchester Commons of Presbyterian Seniorcare, 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 # 075602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 8, 2024, it was determined that Manchester Commons of Presbyterian Seniorcare 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 V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to maintain emergency lighting, in accordance with regulations, affecting two of two components.

Findings include:

Document review on August 8, 2024, at 9:22 a.m., revealed the facility's last documented annual 90-minute emergency light test occurred in June 2023.

Interview with the maintenance supervisor on August 8, 2024, at 9:22 a.m., confirmed the emergency light deficiency.

Plan of Correction - To be completed: 10/17/2024

1) The 90-minute emergency light test will be completed in August of 2024. The PM for the 90-minute emergency light test will be updated to completed on or before August of 2025 rather than anytime in 2025 as it was previously done.
2) This deficiency and subsequent plan of correction will be reviewed and the next quality assurance committee meeting.

NFPA 101 STANDARD Exit Signage:

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.

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, the facility failed to maintain exit signage for one of two components.

Findings include:

Observation on August 8, 2024, at 10:10 a.m., revealed the activities room failed to have exit signage to direct residents to a nearby emergency exit.

Interview with the maintenance supervisor on August 8, 2024, at 10:10 a.m., confirmed the exit signage deficiency.

Plan of Correction - To be completed: 10/07/2024

1) Exit signage will be added to the Personal Care Activity Room.

2) This deficiency and subsequent plan of correction will be reviewed at the next quality assurance committee meeting.

Initial comments:Name: NEW ADDITION - Component: 02 - Tag: 0000

Facility ID # 075602
Component 02
New Addition

Based on a Medicare/Medicaid Recertification Survey completed on August 8, 2024, it was determined that Manchester Commons of Presbyterian Seniorcare was not in compliance with the 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 two-story, Type II (111), protected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: NEW ADDITION - Component: 02 - Tag: 0291

Based on document review and interview, the facility failed to maintain emergency lighting, in accordance with regulations, affecting two of two components.

Findings include:

Document review on August 8, 2024, at 9:22 a.m., revealed the facility's last documented annual 90-minute emergency light test occurred in June 2023.

Interview with the maintenance supervisor on August 8, 2024, at 9:22 a.m., confirmed the emergency light deficiency.

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