Pennsylvania Department of Health
MCMURRAY HILLS MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MCMURRAY HILLS 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# 130102
Component 01
Main Building

Based on a Relicensure Survey completed on October 21, 2025, it was determined that McMurray Hills Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

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

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

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

Based on documentation review and interview, it was determined the facility failed to perform the required biennial smoke detector sensitivity testing over the last 24 months, affecting the entire facility.

Findings Include:

1. Review of documentation on October 21, 2025, at 9:15 a.m., revealed the facility lacked documentation for the biennial smoke detector sensitivity test.

Interview with the Facility Administrator and Maintenance Director on October 21, 2025, at 1:00 p.m., confirmed the facility lacked documentation for the biennial smoke detector sensitivity test.

Plan of Correction - To be completed: 11/21/2025

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."

Facility on 10/24/2025 had the biennial smoke detector sensitivity test

audits will be completed by maintenance and or designee and reported at monthly QA

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 the sprinkler system in one instance, affecting one of nine smoke compartments.

Findings include:

1. Observation on October 21, 2025, at 10:55 a.m., revealed there was a gap in the ceiling tiles greater than 1/8 inch in the A-Wing Nurse's Storage closet, which would allow the passage of heat and smoke.

Interview with the Facility Administrator and Maintenance Director on October 21, 2025, at 1:00 p.m., confirmed the sprinkler system deficiency.

Plan of Correction - To be completed: 11/21/2025

Maintenance Director on 10/22/2025 sealed opening with 3M Fireblock caulking.

NFPA 101 STANDARD Portable Fire Extinguishers:

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 documentation review and interview, it was determined the facility failed to maintain portable fire extinguishers in one instance, affecting the entire facility.

Findings include:

1. Documentation review on October 21, 2025, at 8:30 a.m., revealed the facility could not provide a current certificate for the technician that completed the annual portable fire extinguisher inspection.

Interview with the Facility Administrator and Maintenance Director on October 21, 2025, at 1:00 p.m., confirmed the portable fire extinguisher deficiency.

Plan of Correction - To be completed: 11/21/2025

Facility obtained certificate of technician who performed test.

Facility will request from technician a copy of proper certificate upon completion of test performed.

Maintenance Director and/or designee will monitor and report at Monthly QA meeting

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 and readily identifiable. 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 provide an annual fuel quality test report for emergency generator, affecting the entire facility.

Findings include:

1. Review of documentation and interview on October 21, 2025, at 8:35 a.m., revealed the facility failed to perform the annual fuel quality test for the emergency generator.

Interview with the Facility Administrator and Director of Maintenance on October 21, 2025, at 1:00 p.m., confirmed the annual fuel quality test for the emergency generator was not performed in the last 12 months.

Plan of Correction - To be completed: 11/21/2025

FACILITY COMPLETED REQUIRED FUEL TEST ON GENERATOR 10/22/2025.
Facility Maintenance Director and/or designee will monitor monthly and report at QA meeting monthly.

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