Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manchester Commons Of Presbyterian Seniorcare during CMS and state inspections, most recent first.
A resident with multiple chronic conditions had a signed DNR order indicating a wish to allow natural death, but the physician's orders listed Full Code status. The resident confirmed not wanting CPR, and the DON acknowledged the inconsistency between the physician's orders and the resident's documented wishes.
The facility did not provide required written notifications regarding hospital transfers or bed-hold policies to residents and their representatives, and failed to communicate necessary clinical information to receiving healthcare providers for multiple residents with complex medical conditions. These deficiencies were confirmed by review of records and staff interviews.
A resident with a history of stroke, hypertension, and GERD was started on daily insulin for new onset diabetes, as documented in the clinical record and confirmed by MDS assessments. Despite this, no care plan was developed to address the resident's diabetes or insulin therapy, which was confirmed by the DON.
A resident with dementia, anxiety, and GERD was found to be receiving hospice services without a physician's order documented in the medical record. The DON confirmed the absence of the required order despite hospice care being provided.
A resident with dementia and anxiety received PRN Ativan beyond the 14-day limit without a documented clinical rationale for continued use, and there was no evidence that non-pharmacological interventions were attempted prior to each administration. The DON confirmed the lack of required documentation for both the rationale and interventions.
Surveyors found that outdated medications and biologicals, including an open vial of Tubersol and expired bottles of heartburn relief, senna plus, and docusate sodium, were not discarded as required by facility policy and manufacturer guidelines. A nurse confirmed these items were beyond their expiration or recommended use dates and should have been removed.
Survey results and related reports from the past three years were not available in the designated binders for residents and visitors to review in any of the facility's neighborhoods. The NHA confirmed the absence of these required documents, including recent survey results and plans of correction.
The facility failed to develop a baseline care plan for a resident with serious medical conditions within 48 hours of admission and did not provide a summary of the baseline care plan to another resident and their representative. The Director of Nursing confirmed the absence of these care plans.
A facility failed to ensure a resident received care according to professional standards by not obtaining a physician's order for IV flushes before and after administering Vancomycin. The resident, with a spinal abscess and MRSA infection, had no order for the necessary IV flushes, which was confirmed by the DON after a nurse administered the medication without the order.
A facility did not act on a consultant pharmacist's recommendation for a resident with Lewy Body dementia and other conditions. The recommendation for an AIMS assessment was not completed, as confirmed by the DON, despite facility policy requiring such actions to be documented.
The facility failed to store medications subject to abuse, such as Lorazepam, in a separately locked, permanently affixed compartment within a medication refrigerator. An LPN confirmed the absence of the required compartment during an observation.
The facility failed to maintain sanitary food service operations in the Blue [NAME] kitchen due to a malfunctioning temperature dial on the dish machine, preventing verification of the required rinse temperature for proper sanitation. The Director of Dining Services confirmed the issue, which violates the facility's policy and regulatory requirements.
Inconsistent Resuscitation Orders and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's documented wishes regarding resuscitation were accurately reflected and consistently maintained in both the physician's orders and the resident's Resuscitation Authorization. Specifically, a review of the clinical record for a resident with diagnoses including diabetes, chronic obstructive pulmonary disease, and high blood pressure revealed a signed Do Not Resuscitate (DNR) order in the Resuscitation Authorization, while the physician's orders indicated Full Code status, which would require initiation of CPR in the event of cardiac or respiratory arrest. During interviews, the resident confirmed a desire not to receive CPR and to allow natural death, which was not aligned with the current physician's order. The Director of Nursing acknowledged that the physician's orders and the Resuscitation Authorization were inconsistent and confirmed that both should accurately reflect the resident's advance directive wishes. This inconsistency was identified through review of facility policy, clinical records, and staff interviews.
Failure to Provide Required Transfer Notifications and Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident transfers to the hospital for several residents. Specifically, for three residents, there was no documented evidence that written notification of the transfer, including the reason for transfer, was provided to the residents and their representatives. Additionally, the facility did not provide a bed-hold notice to the responsible parties as required by policy. These deficiencies were confirmed through review of clinical records and staff interviews, which revealed that the necessary notifications and documentation were not completed at the time of transfer. Furthermore, for two residents, the facility did not ensure that the necessary clinical information was communicated to the receiving healthcare provider upon transfer to the hospital. The Director of Nursing confirmed that there was no evidence of bed-hold policy notification, including cost per day, or transfer of clinical information for these residents. The residents involved had significant medical histories, including Alzheimer's disease, diabetes, congestive heart failure, and other chronic conditions, and were transferred to the hospital for evaluation or treatment. The lack of required notifications and communication was verified by both the Nursing Home Administrator and the Director of Nursing.
Failure to Develop Care Plan for New Onset Diabetes and Insulin Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident with new onset diabetes who was receiving insulin therapy. According to facility policy, a person-centered care plan with measurable objectives and timetables must be developed for each resident to address their medical, nursing, mental, and psychological needs. The policy also requires the care plan to be reviewed and updated after significant changes in a resident's condition, readmission from a hospital, and at least quarterly. Review of the resident's clinical record showed an admission with diagnoses including stroke, high blood pressure, and GERD. A physician's order was present for daily subcutaneous insulin injections due to new onset diabetes, and quarterly and annual MDS assessments confirmed insulin use during the look-back periods. However, there was no evidence in the clinical record that a care plan had been developed to address the resident's diabetes or insulin therapy. The DON confirmed during interview that no such care plan was in place.
Hospice Services Provided Without Physician Order
Penalty
Summary
A deficiency was identified when a review of clinical records and staff interviews revealed that a resident with diagnoses including dementia, anxiety, and gastroesophageal reflux disease was receiving hospice services without a corresponding physician's order. The resident's clinical record documented the provision of routine hospice care, but there was no evidence of a physician's order authorizing these services. During an interview, the Director of Nursing confirmed both the absence of the required physician's order and the expectation that such an order should be present for hospice services.
Failure to Document Rationale and Non-Pharmacological Interventions for PRN Psychotropic Use
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of a PRN psychotropic medication, specifically Ativan, beyond the 14-day limit for a resident diagnosed with dementia, anxiety, and gastroesophageal reflux disease. The clinical record for this resident showed an initial order for PRN Ativan for 14 days, followed by a renewed order for another 14 days without documentation of a clinical rationale for the continued use. This action was not in accordance with the facility's policy, which requires a documented clinical rationale and evaluation by the provider for continued PRN psychotropic medication use beyond 14 days. Additionally, the resident's medication administration record indicated that PRN Ativan was administered on multiple occasions, but there was no evidence in the clinical record that non-pharmacological interventions were attempted prior to each administration, as required by facility policy. The Director of Nursing confirmed the absence of both a clinical rationale for the continued PRN order and documentation of non-pharmacological interventions prior to medication administration.
Failure to Discard Outdated Medications and Biologicals
Penalty
Summary
The facility failed to appropriately discard outdated medications and biologicals as required by policy and manufacturer guidelines. During a review of the Avonia Springs medication room, an open vial of Tubersol with an open date of 4/4/25 was found, despite manufacturer instructions to discard within 30 days of opening. Additionally, the medication cart contained an open bottle of heartburn relief with an expiration date of 4/2023, an open bottle of senna plus with an expiration date of 9/2024, and an open bottle of docusate sodium with an expiration date of 1/2024. These findings were confirmed by a Registered Nurse at the time of observation, who acknowledged that the identified medications and biologicals were beyond their expiration or recommended use dates and should have been discarded. The facility's own policy requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures, which was not followed in these instances.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the most recent Department of Health survey results were readily accessible to residents and visitors in all five neighborhoods of the facility. Observations conducted on each neighborhood revealed that the State Department of Health Survey binders did not contain information or results from the State Surveys conducted on 8/8/24 and 5/28/25, making them unavailable for examination by residents and visitors. During an interview, the Nursing Home Administrator confirmed that the binders were missing reports for all surveys, certifications, and complaint investigations from the preceding three years, as well as any plan of correction currently in effect.
Failure to Develop and Communicate Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan for one of the residents, identified as Resident R65, within 48 hours of admission. Resident R65 was admitted with serious medical conditions including acute respiratory failure with hypoxia, amyotrophic lateral sclerosis, severe protein-calorie malnutrition, and a gastrostomy. A review of Resident R65's clinical record showed no evidence of a baseline care plan being developed, which was confirmed by the Director of Nursing during an interview. Additionally, the facility did not provide a summary of the baseline care plan to another resident, identified as Resident R175, and their representative. Resident R175 was admitted with conditions such as a fractured left leg, irregular heartbeat, high blood pressure, heart failure, and speech disturbances. The clinical record for Resident R175 lacked evidence that a summary of the baseline care plan was provided, which was also confirmed by the Director of Nursing.
Failure to Obtain Physician's Order for IV Flushes
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The deficiency was identified during a review of the facility's policy, clinical records, observations, and staff interviews. The facility's policy on Infusion Therapies required flushing of the vascular device prior to each infusion, with a legal prescriber's order. However, the clinical record of a resident with a spinal abscess and MRSA infection, who was resistant to Vancomycin-related antibiotics, lacked a physician's order for flushing the IV before and after administering Vancomycin. During an observation, a registered nurse administered Vancomycin intravenously without a physician's order for the necessary IV flushes. The Director of Nursing confirmed the absence of the required physician's order in the resident's clinical record.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the consultant pharmacist were acted upon for a resident reviewed for unnecessary medications. The facility's policy, dated February 1, 2024, requires that recommendations from the consultant pharmacist be acted upon and documented by the community staff and/or the prescriber. However, for a resident with diagnoses including Lewy Body dementia, high blood pressure, falls, difficulty speaking, and moderate agitation, there was no evidence that a pharmacy consultant's recommendation for an Abnormal Involuntary Movement Scale (AIMS) assessment, dated July 3, 2024, was completed. This deficiency was confirmed during an interview with the Director of Nursing on August 8, 2024, who acknowledged the lack of evidence for the completion of the AIMS assessment.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that medications subject to abuse were stored in compliance with regulatory requirements. During an observation on August 8, 2024, at 9:30 a.m., it was noted that a locked refrigerator in the Blue [NAME] Medication Room contained an unopened multi-dose vial of liquid Lorazepam, an antianxiety medication, which was not stored in a separately locked, permanently affixed compartment as required. This observation was confirmed by Licensed Practical Nurse Employee E2, who acknowledged that the refrigerator lacked the necessary compartment for storing medications subject to abuse.
Sanitation Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary food service operations in the Blue [NAME] kitchen. The deficiency was identified through a review of the facility's policy on dietary sanitization and observations made during a survey. The policy, dated 2/01/24, specifies that high-temperature dishwashers must operate with a wash temperature between 150 and 165 degrees Fahrenheit for at least 45 seconds and a rinse temperature between 165 and 180 degrees Fahrenheit for at least 12 seconds. However, during an observation on 8/06/24, it was noted that the temperature dial for the rinse cycle of the dish machine in the Blue [NAME] kitchen was not functioning, with the needle resting on 0, indicating that the rinse temperature could not be assessed. The Director of Dining Services confirmed during an interview that the dish machine's rinse cycle temperature could not be verified due to the malfunctioning temperature dial. This failure to ensure the rinse temperature met the required 180 degrees Fahrenheit for proper sanitation constitutes a breach of the facility's policy and regulatory requirements under 28 Pa. Code 201.14(a) and 28 Pa. Code 211.6(f).
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Erie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairview Manor | 0.3 mi | ★★★★★ | 15 | 0 |
| Lecom At Asbury Ridge Dba Saint Mary's Asbury Ridg | 2 mi | ★★★★★ | 9 | 0 |
| Pleasant Ridge Manor East/west | 2.4 mi | ★★★★★ | 0 | 0 |
| Walnut Creek Nursing And Rehab | 5.3 mi | ★★★★★ | 14 | 0 |
| Lecom At Presque Isle, Inc | 5.8 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.