Pennsylvania Department of Health
 MANATAWNY CENTER FOR REHABILITATION AND NURSING
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANATAWNY CENTER FOR REHABILITATION AND NURSING
Inspection Results For:

There are  48 surveys for this facility. Please select a date to view the survey results.

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MANATAWNY CENTER FOR REHABILITATION AND NURSING - 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 4, 2026, at Manatawny 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 #130802   Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on March 4, 2026, it was determined that Manatawny Center for Rehabilitation and Nursing 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 two-story, Type III (200), unprotected ordinary structure, with a partial basement, which is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN - Component: 01 - Tag: 0161 Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting two of two floors within the component. Findings include: 1. Observation on March 4, 2026, at 11:00 AM, revealed the building was a two-story, Type III (200), unprotected ordinary structure, which is fully sprinklered. This type of construction is limited to one story in height. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the construction type is not allowed in health care.
 Plan of Correction - To be completed: 03/31/2026

1.The facility is requesting DSI to complete an FSES inspection.
NFPA 101 STANDARD Emergency Lighting: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.
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 perform maintenance of battery-powered emergency lighting, affecting the entire component. Findings include: 1. Review of documentation on March 4, 2026, between 9:15 AM and 10:45 AM, revealed the facility failed to perform one full year of monthly and annual testing of battery powered emergency lighting sources. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the facility failed to perform one full year of monthly and annual testing of battery powered emergency lighting.
 Plan of Correction - To be completed: 03/31/2026

1.The Maintenance Director has scheduled and completed monthly and annual testing of all battery-powered emergency lighting sources throughout the facility. Monthly 30-second functional tests and annual 90-minute tests will be performed going forward and documented in the Life Safety Book.
2.The Maintenance Director and relevant staff members will be educated on NFPA 101 Emergency Lighting requirements, with specific focus on the requirement for monthly 30-second tests and annual 90-minute tests of battery-powered emergency lighting units.
3.The Maintenance Director/designee will conduct monthly functional tests of all battery-powered emergency lighting units, documenting results in the Life Safety Book. The NHA/designee will review the documentation during monthly audits to verify compliance with testing requirements.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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 - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain hazardous area rated doors to be within the allowed gap margins, maintain rated fire label, and failed to close, in one of eleven smoke zones within the component. Findings include: 1. Observation on March 4, 2026, at 11:35 AM, revealed the basement Boiler Room door, left leaf, failed to close, due to faulty coordinator. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the Boiler Room door, left leaf, failed to close. 2. Observation on March 4, 2026, at 11:35 AM, revealed the basement Central Supply Room door, lacked a fire rated label. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the Central Supply Room door lacked a rated label. 3. Observation on March 4, 2026, at 12:00 PM, revealed the basement Central Supply Room, Medical Records door, exceeded required door gap, of 1/8 at the top. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the Medical Records Room door exceeded minimum gap requirements.
 Plan of Correction - To be completed: 04/17/2026

1.The Maintenance Director will complete or arrange the following repairs:
a. Repair or replace the faulty coordinator on the Boiler Room door to restore proper closing and latching.
b. Work with a qualified fire door vendor to either obtain certification for the unlabeled Central Supply Room door or replace it with a new, labeled fire door assembly that meets NFPA 80 requirements.
c. Adjust the door gap on the Medical Records door to meet the 1/8 inch tolerance requirement.
2.The Maintenance Director and relevant staff members will be educated on NFPA 101 Hazardous Areas - Enclosure requirements, with specific focus on maintaining fire rated doors with proper labeling, latching, and gap margins.
3.The Maintenance Director/designee will conduct monthly audits of all hazardous area doors to ensure continued compliance with closing, latching, gap, and labeling requirements. Findings will be documented and reviewed.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.


NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN - Component: 01 - Tag: 0351 Based on observation and interview, it was determined the facility failed to provide complete sprinkler coverage of all useable areas, affecting one of eleven smoke zones within the component. Findings include: 1. Observation on March 4, 2026, at 11:45 AM, revealed the basement Electrical room, Transfer Switch Control Room lacked a sprinkler head beneath the lowest landing. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the lack of sprinkler protection
 Plan of Correction - To be completed: 05/03/2026

1.The Maintenance Director will engage a qualified fire sprinkler contractor (Johnson Controls) to evaluate and extend sprinkler coverage into the basement Electrical room, Transfer Switch Control Room to ensure complete sprinkler protection of all useable areas. The work will be scheduled and completed in accordance with NFPA 13 requirements. Plan review contacted for corrective action requirements. The vendor will provide plan drawings and hydraulic calculations for submission to plan review for approval.
2.The Maintenance Director and relevant staff members will be educated on NFPA 101 Sprinkler System - Installation requirements, with specific focus on the requirement for complete sprinkler coverage of all useable areas.
3.The Maintenance Director/designee will conduct a thorough inspection of all sprinklered areas within the facility to verify complete coverage. Any additional areas of concern will be addressed immediately. Monthly audits will be conducted to ensure no new areas of incomplete coverage develop.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 maintain the automatic sprinkler system to be free of obstructions, affecting one of eleven smoke compartments within the component. Findings include: 1. Observation on March 4, 2026, between 11:20 AM and 11:25 AM, revealed sprinkler heads covered with debris, at the following locations: a. 11:20 AM, Laundry Room, wash area, 5 sprinkler heads; b. 11:25 AM, Laundry Room, folding area, 2sprinkler heads. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the debris on the sprinkler heads.
 Plan of Correction - To be completed: 03/31/2026

1.The Maintenance Director has scheduled and completed cleaning of all affected sprinkler heads in the Laundry Room wash area (5 heads) and folding area (2 heads). A full facility inspection of all sprinkler heads has been conducted to ensure no additional heads are obstructed.
2.The Maintenance Director and relevant staff members will be educated on NFPA 25 Sprinkler System - Maintenance and Testing requirements, with specific focus on keeping sprinkler heads free from dust, debris, and obstructions.
3.The Maintenance Director/designee will conduct quarterly inspections of all sprinkler heads within the facility to verify they remain free from obstructions. Findings will be documented and reported for further action, if necessary.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to perform required annual maintenance and testing, for the emergency generator, which serves the entire component. Findings include: 1. Review of documentation on March 4, 2026, between 9:15 AM and 10:45 AM, revealed the facility failed to perform the annual load bank test. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the facility failed to perform the annual load bank test.
 Plan of Correction - To be completed: 03/31/2026

1.The Maintenance Director scheduled and completed the annual 90-minute load bank test with the generator vendor on March 6, 2026. The test report has been placed in the Life Safety Book. All future required annual load bank tests will be scheduled and completed in accordance with NFPA 110 requirements.
2.The Maintenance Director and relevant staff members will be educated on NFPA 110 Electrical Systems - Essential Electric System requirements, with specific focus on the requirement for annual 90-minute load bank testing and documentation.
3.The Maintenance Director/designee will maintain written records of all generator maintenance and testing in the Life Safety Book, including weekly inspections, monthly load tests, and annual load bank tests. The NHA/designee will review the documentation during monthly audits to verify completion and availability.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.


Initial comments:Name: A-B - Component: 02 - Tag: 0000
Facility ID #130802   Component 02A-B Addition Based on a Medicare/Medicaid Recertification Survey completed on March 4, 2026, it was determined that Manatawny Center for Rehabilitation and Nursing 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 (111), protected noncombustible structure, without a basement, which is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
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: A-B - Component: 02 - Tag: 0291 Based on document review and interview, it was determined the facility failed to perform maintenance of battery-powered emergency lighting, affecting the entire component. Findings include: 1. Review of documentation on March 4, 2026, between 9:15 AM and 10:45 AM, revealed the facility failed to perform one full year of monthly and annual testing of battery powered emergency lighting sources. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the facility failed to perform one full year of monthly and annual testing of battery powered emergency lighting.
 Plan of Correction - To be completed: 03/31/2026

1.The Maintenance Director has scheduled and completed monthly and annual testing of all battery-powered emergency lighting sources throughout the facility. Monthly 30-second functional tests and annual 90-minute tests will be performed going forward and documented in the Life Safety Book.
2.The Maintenance Director and relevant staff members will be educated on NFPA 101 Emergency Lighting requirements, with specific focus on the requirement for monthly 30-second tests and annual 90-minute tests of battery-powered emergency lighting units.
3.The Maintenance Director/designee will conduct monthly functional tests of all battery-powered emergency lighting units, documenting results in the Life Safety Book. The NHA/designee will review the documentation during monthly audits to verify compliance with testing requirements.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: A-B - Component: 02 - Tag: 0918 Based on document review and interview, it was determined the facility failed to perform required annual maintenance and testing, for the emergency generator, which serves the entire component. Findings include: 1. Review of documentation on March 4, 2026, between 9:15 AM and 10:45 AM, revealed the facility failed to perform the annual load bank test. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the facility failed to perform the annual load bank test.
 Plan of Correction - To be completed: 03/31/2026

1.The Maintenance Director scheduled and completed the annual 90-minute load bank test with the generator vendor on March 6, 2026. The test report has been placed in the Life Safety Book. All future required annual load bank tests will be scheduled and completed in accordance with NFPA 110 requirements.
2.The Maintenance Director and relevant staff members will be educated on NFPA 110 Electrical Systems - Essential Electric System requirements, with specific focus on the requirement for annual 90-minute load bank testing and documentation.
3.The Maintenance Director/designee will maintain written records of all generator maintenance and testing in the Life Safety Book, including weekly inspections, monthly load tests, and annual load bank tests. The NHA/designee will review the documentation during monthly audits to verify completion and availability.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.

Initial comments:Name: B-C - Component: 03 - Tag: 0000
Facility ID #130802   Component 03B-C Addition Based on a Medicare/Medicaid Recertification Survey completed on March 4, 2026, it was determined that Manatawny Center for Rehabilitation and Nursing 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 two-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
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: B-C - Component: 03 - Tag: 0291 Based on document review and interview, it was determined the facility failed to perform maintenance of battery-powered emergency lighting, affecting the entire component. Findings include: 1. Review of documentation on March 4, 2026, between 9:15 AM and 10:45 AM, revealed the facility failed to perform one full year of monthly and annual testing of battery powered emergency lighting sources. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the facility failed to perform one full year of monthly and annual testing of battery powered emergency lighting.
 Plan of Correction - To be completed: 03/31/2026

1.The Maintenance Director has scheduled and completed monthly and annual testing of all battery-powered emergency lighting sources throughout the B-C Addition. Monthly 30-second functional tests and annual 90-minute tests will be performed going forward and documented in the Life Safety Book.
2.The Maintenance Director and relevant staff members will be educated on NFPA 101 Emergency Lighting requirements, with specific focus on the requirement for monthly 30-second tests and annual 90-minute tests of battery-powered emergency lighting units.
3.The Maintenance Director/designee will conduct monthly functional tests of all battery-powered emergency lighting units, documenting results in the Life Safety Book. The NHA/designee will review the documentation during monthly audits to verify compliance with testing requirements.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: B-C - Component: 03 - Tag: 0918 Based on document review and interview, it was determined the facility failed to perform required annual maintenance and testing for the emergency generator, which serves the entire component. Findings include: 1. Review of documentation on March 4, 2026, between 9:15 AM and 10:45 AM, revealed the facility failed to perform the annual load bank test. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the facility failed to perform the annual load bank test.
 Plan of Correction - To be completed: 03/31/2026

1.The Maintenance Director scheduled and completed the annual 90-minute load bank test with the generator vendor on March 6, 2026. The test report has been placed in the Life Safety Book. All future required annual load bank tests will be scheduled and completed in accordance with NFPA 110 requirements.
2.The Maintenance Director and relevant staff members will be educated on NFPA 110 Electrical Systems - Essential Electric System requirements, with specific focus on the requirement for annual 90-minute load bank testing and documentation.
3.The Maintenance Director/designee will maintain written records of all generator maintenance and testing in the Life Safety Book, including weekly inspections, monthly load tests, and annual load bank tests. The NHA/designee will review the documentation during monthly audits to verify completion and availability.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting.

Initial comments:Name: BUILDING 04 - Component: 04 - Tag: 0000
Facility ID #130802   Component 04Adult Day Care Building Based on a Medicare/Medicaid Recertification Survey completed on March 4, 2026, it was determined that Manatawny Center for Rehabilitation and Nursing 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 (211), protected ordinary structure, without a basement, which is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
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: BUILDING 04 - Component: 04 - Tag: 0291 Based on document review and interview, it was determined the facility failed to perform maintenance of battery-powered emergency lighting, affecting the entire component. Findings include: 1. Review of documentation on March 4, 2026, between 9:15 AM and 10:45 AM, revealed the facility failed to perform one full year of monthly and annual testing of battery powered emergency lighting sources. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the facility failed to perform one full year of monthly and annual testing of battery powered emergency lighting.
 Plan of Correction - To be completed: 03/31/2026

1.The Maintenance Director has scheduled and completed monthly and annual testing of all battery-powered emergency lighting sources throughout the Adult Day Care Building. Monthly 30-second functional tests and annual 90-minute tests will be performed going forward and documented in the Life Safety Book.
2.The Maintenance Director and relevant staff members will be educated on NFPA 101 Emergency Lighting requirements, with specific focus on the requirement for monthly 30-second tests and annual 90-minute tests of battery-powered emergency lighting units.
3.The Maintenance Director/designee will conduct monthly functional tests of all battery-powered emergency lighting units, documenting results in the Life Safety Book. The NHA/designee will review the documentation during monthly audits to verify compliance with testing requirements.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0918 Based on document review and interview, it was determined the facility failed to perform required annual maintenance and testing, for the emergency generator, which serves the entire component. Findings include: 1. Review of documentation on March 4, 2026, between 9:15 AM and 10:45 AM, revealed the facility failed to perform the annual load bank test. Interview at the time of the exit conference with the Administrator and Facilities Manager on March 4, 2026, at 1:15 PM, confirmed the facility failed to perform the annual load bank test.
 Plan of Correction - To be completed: 03/31/2026

1.The Maintenance Director scheduled and completed the annual 90-minute load bank test with the generator vendor on March 6, 2026. The test report has been placed in the Life Safety Book. All future required annual load bank tests will be scheduled and completed in accordance with NFPA 110 requirements.
2.The Maintenance Director and relevant staff members will be educated on NFPA 110 Electrical Systems - Essential Electric System requirements, with specific focus on the requirement for annual 90-minute load bank testing and documentation.
3.The Maintenance Director/designee will maintain written records of all generator maintenance and testing in the Life Safety Book, including weekly inspections, monthly load tests, and annual load bank tests. The NHA/designee will review the documentation during monthly audits to verify completion and availability.
4.Findings will be reviewed at the Quality Assurance Performance Improvement meeting


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