Pennsylvania Department of Health
CHAPEL 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.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


CHAPEL MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 031602
Component 01
Room C235, Second Floor Rooms, First Floor Corridor, Basement Corridor, Basement Mechanical Rooms.

Based on an Abbreviated survey, as part of a complaint investigation completed on April 28, 2025, it was determined that Chapel Manor - Room C235, Second Floor Rooms, First Floor Corridor, Basement Corridor, Basement Mechanical Rooms Area, was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy.

This is a two-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation review and interview, it was determined the facility failed to maintain the fire alarm system in proper operating condition, affecting the entire facility.

Findings Include:

Observation on April 28, 2025, at 1:15 p.m., revealed the facility fire alarm panel was in trouble mode at the time of survey.

Exit Interview with the Administrator and Maintenance Director on April 28, 2025, at 2:30 p.m., confirmed the fire alarm panel trouble status.

Plan of Correction - To be completed: 06/09/2025

The fire alarm system has been repaired and is operating properly.

Senior maintenance director/NPE/designee will re-educate maintenance staff on proper maintenance of the fire panel system.

NHA/designee will complete monthly audits to ensure compliance.

Maintenance director will report the findings of the audits to the QAPI Committee monthly X 3 months

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 BUILDING 01 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of three levels.

Findings include:

Observation on April 28, 2025, at 12:30 p.m., revealed multiple sprinklers obstructed by clear plastic material used as part of the ceiling assembly. The corridor ceiling had water damage due to recent fire event, first floor corridor near lobby.

Exit Interview with the Administrator and Maintenance Director on April 28, 2025, at 2:30 p.m., confirmed the obstructed sprinklers.

Plan of Correction - To be completed: 06/09/2025

The plastic cover was immediately removed from the sprinkler head.
The ceiling tiles have been replaced.

senior maintenance director/NPE/designee will re-educate maintenance staff on the importance of keeping sprinkler head unobstructed from any material

The maintenance director will complete initial audits of the hallways sprinkler head for obstructions.

NHA/designee will complete weekly audits to ensure compliance.

Maintenance director will report the findings of the audits to the QAPI Committee monthly X 3 months

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