Pennsylvania Department of Health
PENNSBURG MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PENNSBURG 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 14, 2025, at Pennsburg 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 #162402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 14, 2025, it was determined that Pennsburg 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 three-story, Type II (111), protected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Portable Fire Extinguishers:

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.

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 document review and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility.

Findings:

Document review on May 14, 2025, at 8:30 a.m., revealed the following:

a. The facility could not produce documentation of an annual fire extinguisher inspection.
b. The facility could not produce a certificate for the technician conducting the annual fire extinguisher inspections.

Exit interview with the Administrator and Director of Maintenance on May 14, 2025, at 11:30 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/15/2025

The documentation of an annual fire extinguisher inspection and certificate for the technician conducting the annual fire extinguisher inspections were placed in the Life Safety binder.
The Maintenance Director will audit the Life Safety paperwork on a monthly basis.
The Maintenance Director will develop a Life Safety paperwork audit to ensure that the proper paperwork is sent by the vendor following each periodic inspection and placed in the Life Safety binder.
Life Safety paperwork tracker will be completed by the Maintenance Director and approved by the Administrator by June, 15th, 2025.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke doors, affecting one of three levels.

Findings include:

Observation on May 14, 2025, at 10:30 a.m., revealed North double doors did not close smoke tight when tested, on the ground floor, leading to the Kitchen.

Exit interview with the Administrator and Director of Maintenance on May 14, 2025, at 11:30 a.m., confirmed the doors failed to close smoke tight.

Plan of Correction - To be completed: 06/15/2025

The North double doors on the ground floor leading to the kitchen were adjusted to maintain smoke door standards.
The Maintenance Director will verify, on a monthly basis, proper closure of the affected doors.
The Maintenance Director will complete a monthly audit in TELs for the Smoke Barrier doors on the Ground Floor North Hall to close properly upon Fire System actuation.
Results of the audit will be reported to the Quality Assurance Performance Improvement Committee and Life Safety Committee monthly.

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 BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the generator, affecting the entire facility.

Findings include:

Document review on May 14, at 8:30 a.m., revealed the facility could not produce documentation of the Annual Fuel Quality Test.

Exit interview with the Administrator and Director of Maintenance on May 14, 2025, at 11:30 a.m., confirmed the missing fuel quality report.

Plan of Correction - To be completed: 06/15/2025

The documentation of the Annual Fuel Quality Test was placed in the binder.
The Maintenance Director will audit the Life Safety paperwork on a monthly basis.
The Maintenance Director will develop a Life Safety paperwork audit to ensure that the proper paperwork is sent by the vendor following each periodic inspection and placed in the Life Safety binder.
Life Safety paperwork tracker will be completed by the Maintenance Director and approved by the Administrator by June, 15th, 2025.

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