Pennsylvania Department of Health
CHRIST THE KING MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 52 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.


CHRIST THE KING 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 June 4, 2024, at Christ the King 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 #290102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 4, 2024, it was determined that Christ the King 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 II (000), unprotected, non-combustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Receptacles:

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.

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical systems in wet locations, affecting one of three building components.

Findings include:

Observation on June 4, 2024, at 10:00 a.m., revealed the first floor laundry room had electrical outlets located within six feet of the washing machines, but were not ground fault circuit interrupter (GFCI) receptacles.

Interview with the maintenance supervisor on June 4, 2024, at 10:00 a.m., confirmed the receptacle deficiencies.

Plan of Correction - To be completed: 06/06/2024

K-0912 NFPA 101 Standard- Electrical Systems- Receptacles

Christ the King Manor intents to meet receptacle requirements. Corrective action to address the deficient practice was on June 4, 2024. A ground fault circuit interrupter (GFCI) was installed on the Laundry room, the deficiency contained receptacle located within six feet of a water source and not properly protected by a ground fault circuit interrupter.

Corrective action will be completed on June 6, 2024.

Systematic changes that will be implemented to ensure deficient practice does not recur are as follows; Safety Director and/or Maintenance staff inspected all rooms for ground fault circuit interrupter next to any water source. Inspection completed on June 6, 2024 found to be in compliance. Safety Director and/or Maintenance Director will educate all maintenance staff related to proper usage of ground fault circuit interrupter receptacles. The Maintenance Director and/or designee will inspect for ground fault circuit interrupter weekly for 2 weeks, bi-weekly for a month, and monthly for two months to ensure compliance.

Corrective action will be monitored by providing results to Quality Assurance Performance Improvement Committee for review, recommendations and compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

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, the facility failed to meet essential electrical system maintenance and testing requirements for one of one facility.

Findings include:

Document review on June 4, 2024, at 10:02 a.m., revealed the facility was unable to provide monthly conductance test documentation.

Interview with the maintenance supervisor and administrator on June 4, 2024, at 10:02 a.m., confirmed the facility was unable to provide the reports at the time of the survey.

Plan of Correction - To be completed: 06/06/2024

K-0918 NFPA 101 Standard Electrical Systems-Essential Electric System Maintenance

Christ the King Manor intents to meet all essential electric system maintenance and testing requirements. Corrective action to address the deficient practice was on June 4, 2024. A conductivity meter was used to test the battery to ensure it was capable of supplying service within 10 seconds.

Corrective action will be completed on June 6, 2024.

Systematic changes that will be implemented to ensure deficient practice does not recur are as follows; Safety Director and/or Maintenance staff completed conductance test and completed documentation. Inspection on June 6, 2024 found to be in compliance. Safety Director and/or Maintenance Director will educate all maintenance staff related to conducting testing to ensure generator or alternate power source and associated equipment is capable of supplying service within 10 seconds on a monthly basis. The Maintenance Director and/or designee will audit for documentation for conductance test and documentation being completed monthly for 3 months to ensure compliance.

Corrective action will be monitored by providing results to Quality Assurance Performance Improvement Committee for review, recommendations and compliance.

Initial comments:Name: CHAPEL - Component: 02 - Tag: 0000

Facility ID #290102
Component 02
Chapel

Based on a Medicare/Medicaid Recertification Survey completed on June 4, 2024, it was determined that Christ the King 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 V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: CHAPEL - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to meet essential electrical system maintenance and testing requirements for one of one facility.

Findings include:

Document review on June 4, 2024, at 10:02 a.m., revealed the facility was unable to provide monthly conductance test documentation.

Interview with the maintenance supervisor and administrator on June 4, 2024, at 10:02 a.m., confirmed the facility was unable to provide the reports at the time of the survey.

Initial comments:Name: NEW DEMENTIA WING - Component: 03 - Tag: 0000

Facility ID #290102
Component 03
Dementia Unit

Based on a Medicare/Medicaid Recertification Survey completed on June 4, 2024, it was determined that Christ the King 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 II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: NEW DEMENTIA WING - Component: 03 - Tag: 0918

Based on document review and interview, the facility failed to meet essential electrical system maintenance and testing requirements for one of one facility.

Findings include:

Document review on June 4, 2024, at 10:02 a.m., revealed the facility was unable to provide monthly conductance test documentation.

Interview with the maintenance supervisor and administrator on June 4, 2024, at 10:02 a.m., confirmed the facility was unable to provide the reports at the time of the survey.

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