Pennsylvania Department of Health
LUTHER ACRES MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 59 surveys for this facility. Please select a date to view the survey results.

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LUTHER ACRES 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 March 5, 2026, at Luther Acres Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN - Component: 01 - Tag: 0000
Facility ID #122402Component 01 Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on March 5, 2026, it was determined that Luther Acres Manor 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 III (200), unprotected ordinary structure, with a partial basement, which 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 - Component: 01 - Tag: 0291 Based on document review and interview, it was determined the facility failed to provide documentation for a 90-minute annual battery-operated light test, in one of one generator enclosure outside the component. Findings include: 1. Review of documentation on March 5, 2026, at 11:07 AM, revealed the facility was unable to provide documentation for the annual 90-minute battery-operated light test for the generator enclosure back-up emergency lighting, which includes the ATS switch. Interview at the time of the exit conference with the Administrator and the Maintenance Director on March 5, 2026, at 11:50 AM, confirmed the facility could not provide documentation of the 90-minute annual battery-operated light test.

Plan of Correction - To be completed: 04/17/2026

90 Minute annual battery-operated light test conducted on 3/17/2026.

Maintenance Director/Designee will conduct annual battery-operated light test annually and document on Maintenance log.

Maintenance Director/Designee will audit monthly Maintenance logs and report findings to QAA Committee.

NFPA 101 STANDARD Cooking Facilities:

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.

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: MAIN - Component: 01 - Tag: 0324 Based on observation and interview, it was determined the facility failed to document the owner's monthly quick checks on the fixed chemical extinguishing system, in one of ten smoke zones within the component. Findings include: 1. Observation on March 5, 2026, at 10:15 AM, revealed the Kitchen fixed chemical suppression system had not been checked for the monthly owner's quick checks since November 2025. Interview at the time of the exit conference with the Administrator and the Maintenance Director on March 5, 2026, at 11:50 AM, confirmed the Kitchen fixed chemical suppression system had not been checked since November 2025.

Plan of Correction - To be completed: 04/17/2026

Monthly quick check on the fixed chemical extinguishing system completed on 3/17/2026.

Maintenance Director/Designee will complete monthly checks of the fixed chemical extinguishing system.

Maintenance Director/Designee will audit monthly quick checks and report findings to QAA Committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 - Component: 01 - Tag: 0353 Based on observation and interview, it was determined the facility failed to monitor the sprinkler system supervisory boxes to be secured, and one of each sprinkler head type was on site, for one of one sprinkler system which serves the entire facility. Findings include: 1. Observation on March 5, 2026, at 9:15 AM, revealed the sprinkler system supervisory box lid was not secured to its base, but could be lifted off, and therefore could not prevent moisture from impacting the circuitry. Interview at the time of the exit conference with the Administrator and the Maintenance Director on March 5, 2026, at 11:50 AM, confirmed the supervisory box lid was not secured to its base. 2. Observation on March 5, 2026, at 9:25 AM and at 10:05 AM, revealed the facility lacked 2 of the 3 spare sprinkler head types found within the facility (quick response heads in Laundry, green and red bulbs vs fusible links). Interview at the time of the exit conference with the Administrator and the Maintenance Director on March 5, 2026, at 11:50 AM, confirmed the facility did not have spare quick response heads with green and/or red bulbs.

Plan of Correction - To be completed: 04/17/2026

Sprinkler system supervisory box lid has been secured.

Spare sprinkler heads have been purchased.

When sprinkler vendor has performed work, Maintenance Director/Designee will confirm that all supervisory boxes have been secured to their base.

Maintenance Director/Designee will audit spare sprinkler head availability x3 months then quarterly and report findings to QAA Committee.

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 - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to maintain junction boxes to be covered, in one of ten smoke zones within the component. Findings include: 1. Observation on March 5, 2026, at 9:16 AM, revealed the junction box, by the sprinkler main supervisor switch, was not covered. The cover was placed against the wall, behind the electrical conduit. Interview at the time of the exit conference with the Administrator and the Maintenance Director on March 5, 2026, at 11:50 AM, confirmed the junction box was not covered.

Plan of Correction - To be completed: 04/17/2026

Junction box by the sprinkler main supervisor switch has been covered.

Maintenance Director/Designee will audit junction box by the sprinkler main supervisor switch when ever electrical work has been conducted and monthly x 3 months to ensure it is covered.

Maintenance Director/Designee will report audits findings to QAA Committee.

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