Pennsylvania Department of Health
NAAMANS CREEK COUNTRY MANOR
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 40 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.


NAAMANS CREEK COUNTRY MANOR - 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 12, 2025, at Naamans Creek Country Manor, 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# 122302
Building 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 12, 2025, it was determined that Naamans Creek Country Manor 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 two-story, Type II (111), protected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Initiation:

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 - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices based on NFPA 72 chapter 10 for circuit identification and accessibility, affecting the entire facility.
Findings include:
Observation on May 12, 2025, at 10:14 a.m., revealed that no labeling for the branch circuit or red labeling could be identified for the fire alarm, which is required to be permanently identifiable.
Exit interview with the Maintenance Director on May 12, 2025, at 10:30 a.m., confirmed the proper circuit identification was missing from electrical room on the first floor.

Plan of Correction - To be completed: 06/09/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

1. Red labeling placed on branch circuit for fire alarm system in electrical room.

2. Maintenance Director and assistant re-educated on red labeling of branch circuit for fire alarm system.

3. Maintenance Director or Designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that red labeling on branch circuit is in place. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, affecting the entire facility.
Findings include:
Observation on May 12, 2025, at 10:00 a.m., revealed the March 12, 2025, fire alarm service report listed the following deficiency, which remained uncorrected at time of survey:
a. The fire alarm annunciator indicated an open supervisory alarm for a heat/Co combination device located in the boiler room on the first floor.
Exit Interview with the Maintenance Director on May 12, 2025, at 10:30 a.m., confirmed the fire alarm deficiency.

Plan of Correction - To be completed: 06/09/2025

1. Fire alarm system in normal mode

2. Fire alarm company in to address supervisory alarm

3. Maintenance Director, maintenance assistant, and supervisors re-educated on addressing fire alarm supervisory alarm.

4. Maintenance Director or Designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that alarm system is in normal mode. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers were accessible and mounted in accordance NFPA 10, affecting the entire facility.
Findings include:
Observation on May 12, 2025, at 10:07 a.m., revealed on the first floor, in the electrical room, the wall mounted fire extinguisher was obstructed by a transformer and mounted more than 5 ft above the ground from the handle of the extinguisher. Condition of excessive height for extinguisher mounting in accordance with NFPA 10 chapter 6 was noted throughout the facility.
Exit Interview with the Maintenance Director on May 12, 2025, at 10:30 a.m., confirmed the obstructed fire extinguisher and several mounting deficiencies.

Plan of Correction - To be completed: 06/09/2025

1. Fire extinguisher re-mounted to meet compliance.

2. Audit of fire extinguishers completed to ensure compliance in accordance with chapter 6

3. Maintenance Director and assistant re-educated on NFPA 10 chapter 6 requirements.

4. Maintenance Director or Designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify compliance of fire extinguishers placement. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

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