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 54 surveys for this facility. Please select a date to view the survey results.

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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 May 14, 2025, 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 May 14, 2025, 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 Sprinkler System - Installation:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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 BUILDING 01 - Component: 01 - Tag: 0351

Based on observation and interview, the facility failed to install adequate sprinkler heads, for a classified fully sprinkled building, in one of over twenty rooms.

Findings include:

Observation on May 14, 2025, at 11:08 a.m., revealed the facility failed to provide adequate sprinkler coverage in the activities storage closet. No drawings for the location were provided to determine if sprinkler coverage is required in this location.

Reference: NFPA 13.8 (2010)

Interview with the maintenance supervisor on May 14, 2025, at 11:08 a.m., confirmed the lack of sprinkler coverage.

Plan of Correction - To be completed: 05/27/2025

Christ the King Manor is committed to ensuring adequate sprinkler coverage throughout the facility in accordance with regulatory standards. The deficient practice will be addressed on 5-28-2025 by installing a sprinkler head in the activity storage closet, which previously lacked proper sprinkler coverage.
Corrective Action Completion Date: June 17, 2025.
Systematic Changes Implemented:
- The Safety Director and/or Maintenance staff conducted a comprehensive inspection of all closet areas to identify any deficiencies related to sprinkler coverage.
- An inspection conducted on 5-23-2025 confirmed the facility is in compliance with sprinkler system requirements in all other areas. Waiting on completion of correction that is to be completed on 5-28-2025.
- The Safety Director and/or Maintenance Director will provide education to maintenance staff regarding sprinkler system regulations and the importance of adequate coverage in all applicable areas.
- The Maintenance Director and/or designee will perform ongoing inspections of closet areas to ensure continued compliance according to the following schedule:
o Weekly for two weeks
o Bi-weekly for one month
o Monthly for two months
Audit results and compliance status will be reported to the Quality Assurance Performance Improvement (QAPI) Committee for review, recommendations, and ongoing monitoring to ensure sustained compliance.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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.

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined that the facility failed to maintain smoke barrier construction on one of one building level.

Findings include:

Observation on May 14, 2025, between 10:35 a.m. and 10:38 a.m., revealed the following:

A. (10:35 a.m. - 10:38 a.m.) MSU North, emergency power panel room had two instances of unsealed conduit and pipe penetrations through the wall that would allow the transfer of smoke.

Interview with the maintenance supervisor on May 14, 2025, at 10:38 a.m., confirmed the smoke barrier deficiencies.

Plan of Correction - To be completed: 05/27/2025

Christ the King Manor is committed to meeting all regulatory requirements regarding smoke barrier construction. The identified deficient practice was corrected on May 14, 2025, by sealing the conduit and pipe penetration discovered in the emergency power panel room.
Corrective Action Completion Date: May 14, 2025
Systematic Changes Implemented:
- The Safety Director and/or Maintenance staff conducted a thorough inspection of all facility areas to identify any deficiencies related to smoke barrier construction.
- An inspection completed on May 15, 2025, confirmed that the facility is in compliance with smoke barrier requirements.
- The Safety Director and/or Maintenance Director will provide education to all maintenance staff on smoke barrier construction requirements and the importance of maintaining proper fire and smoke separation.
- The Maintenance Director and/or designee will perform routine inspections to identify any unsealed penetrations or deficiencies in smoke barriers according to the following schedule:
o Weekly for two weeks
o Bi-weekly for one month
o Monthly for two months
Audit results and compliance status will be reported to the Quality Assurance Performance Improvement (QAPI) Committee for review, recommendations, and ongoing monitoring to ensure sustained compliance.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to maintain gas equipment storage requirements in one of one storage area.

Findings include:

Observation on May 14, 2025, at 11:17 a.m., revealed the oxygen cylinder storage room had a used oxygen cylinder mixed in with the full cylinder rack. Cylinder separation, with empty and full signs, was also not defined.

Interview with the maintenance supervisor on May 14, 2025, at 11:17 a.m., confirmed the oxygen cylinder deficiencies.

Plan of Correction - To be completed: 05/14/2025

Christ the King Manor is committed to meeting all regulatory requirements related to gas equipment storage. The deficient practice identified was addressed during the inspection on May 14, 2025, at which time the separation of full and empty cylinders was completed.
Corrective Action Completion Date: May 14, 2025.
Systematic Changes Implemented:
- The Safety Director and/or Maintenance staff will inspect all oxygen cylinder storage rooms to ensure full and empty cylinders are properly segregated and that appropriate signage is in place to clearly identify each area.
- An inspection conducted on May 15, 2025, confirmed the facility is in compliance with storage requirements.
- The Safety Director and/or Maintenance Director will provide education to relevant staff on regulatory requirements for the proper storage and segregation of oxygen cylinders.
- Ongoing audits of the oxygen storage areas will be conducted as follows:
o Weekly for two weeks
o Bi-weekly for one month
o Monthly for two months
Audit results and compliance status will be reported to the Quality Assurance Performance Improvement (QAPI) Committee for review, recommendations, and ongoing monitoring to ensure sustained compliance.

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

Facility ID #290102
Component 02
Chapel

Based on a Medicare/Medicaid Recertification Survey completed on May 14, 2025, 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 Subdivision of Building Spaces - Smoke Barrie:

Observations:
Name: CHAPEL - Component: 02 - Tag: 0372

Based on observation and interview, it was determined that the facility failed to maintain smoke barrier construction on one of one building level.

Findings include:

Observation on May 14, 2025, between 10:35 a.m. and 10:38 a.m., revealed the following:

A. (10:35 a.m. - 10:38 a.m.) MSU North, emergency power panel room had two instances of unsealed conduit and pipe penetrations through the wall that would allow the transfer of smoke.

Interview with the maintenance supervisor on May 14, 2025, at 10:38 a.m., confirmed the smoke barrier deficiencies.

Plan of Correction - To be completed: 05/14/2025

Christ the King Manor is committed to meeting all regulatory requirements regarding smoke barrier construction. The identified deficient practice was corrected on May 14, 2025, by sealing the conduit and pipe penetration discovered in the emergency power panel room.
Corrective Action Completion Date: May 14, 2025
Systematic Changes Implemented:
- The Safety Director and/or Maintenance staff conducted a thorough inspection of all facility areas to identify any deficiencies related to smoke barrier construction.
- An inspection completed on May 15, 2025, confirmed that the facility is in compliance with smoke barrier requirements.
- The Safety Director and/or Maintenance Director will provide education to all maintenance staff on smoke barrier construction requirements and the importance of maintaining proper fire and smoke separation.
- The Maintenance Director and/or designee will perform routine inspections to identify any unsealed penetrations or deficiencies in smoke barriers according to the following schedule:
o Weekly for two weeks
o Bi-weekly for one month
o Monthly for two months
Audit results and compliance status will be reported to the Quality Assurance Performance Improvement (QAPI) Committee for review, recommendations, and ongoing monitoring to ensure sustained compliance.

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: CHAPEL - Component: 02 - Tag: 0911

Based on observation and interview, the facility failed to install and maintain electrical outlets, per NFPA 70, for one of over forty outlets.

Findings include:

Observation on May 14, 2025, at 10:25 a.m., revealed the activities room ice machine was not connected to a ground fault circuit interrupter (GFCI)-protected outlet.

Interview with the maintenance supervisor on May 14, 2025, at 10:25 a.m., confirmed the electrical deficiency.

Plan of Correction - To be completed: 05/15/2025

Christ the King Manor is committed to meeting all regulatory requirements related to electrical receptacles. The deficient practice identified was corrected on May 15, 2025, by installing a Ground Fault Circuit Interrupter (GFCI) in the MSU activity room. The identified deficiency involved a receptacle located within six feet of a water source that was not properly protected by a GFCI.
Corrective Action Completion Date: May 15, 2025
Systematic Changes Implemented:
- The Safety Director and/or Maintenance staff conducted a facility-wide inspection of all rooms to verify the presence of properly installed GFCI outlets near any water source.
- An inspection conducted on 5-15-2025 confirmed that all applicable areas are now in compliance.
- The Safety Director and/or Maintenance Director will educate all maintenance personnel on the proper installation and usage of GFCI receptacles in accordance with code requirements.
- To ensure ongoing compliance, the Maintenance Director and/or designee will perform audits of GFCI outlets as follows:
o Weekly for two weeks
o Bi-weekly for one month
o Monthly for two months
Audit results and compliance status will be reported to the Quality Assurance Performance Improvement (QAPI) Committee for review, recommendations, and ongoing monitoring to ensure sustained compliance.

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 May 14, 2025, at Christ The King Manor, it was determined there were no deficiencies identified under the 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 483.70(a).

This is a one-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

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