Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Ephrata Manor
EPHRATA, PA · 120 certified beds · Last Life Safety survey September 20, 2024
CMS Certification Number 395857 · first certified August 1991
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within PA
9 citations — more than 43% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (August 2025 to September 2025), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was September 2024. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 9 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 16, 2022 | 3 |
| November 3, 2023 | 3 |
| September 20, 2024 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2022-12-16 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2023-11-03 |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | 1 | 2024-09-20 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2022-12-16 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-11-03 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-09-20 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2024-09-20 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-11-03 |
What the citations cover
- Smoke Deficiencies 6
- Construction Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Construction Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 20, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 15, 2024) |
November 3, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 3, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 3, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 3, 2023) |
December 16, 2022 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (January 31, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 31, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 31, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.