Inspection Reports for Manchester Commons of Presbyterian Senior Care

6351 WEST LAKE ROAD,, ERIE, PA, 16505

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Deficiencies (last 4 years)

Deficiencies (over 4 years) 12.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

172% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/year

Deficiencies per year

12 9 6 3 0
2021
2022
2023
2025

Census

Latest occupancy rate 80% occupied

Based on a August 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

48 56 64 72 80 88 Jun 2021 Jul 2022 Jan 2023 May 2023 Jul 2023 Aug 2025
Inspection Report Complaint Investigation Census: 64 Capacity: 80 Deficiencies: 2 Aug 12, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Manchester Commons of Presbyterian Senior Care.
Findings
The facility was found to have violations related to abuse and treatment of residents, specifically involving a staff person verbally abusing a resident and treating residents without dignity and respect. A plan of correction was submitted and fully implemented.
Complaint Details
The visit was complaint-related with substantiation of verbal abuse by a staff person towards a resident. The staff person was suspended following the allegation and investigation.
Deficiencies (2)
Description
Failure to immediately develop and implement a plan of supervision or suspend a staff person involved in an alleged abuse incident.
Resident was treated without dignity and respect, with staff responding negatively to toileting assistance requests.
Report Facts
License Capacity: 80 Residents Served: 64 Secured Dementia Care Unit Capacity: 24 Secured Dementia Care Unit Residents Served: 19 Current Hospice Residents: 2 Residents Diagnosed with Mental Illness: 29 Residents with Mobility Need: 29 Residents 60 Years or Older: 64 Residents with Physical Disability: 2
Inspection Report Complaint Investigation Census: 61 Capacity: 80 Deficiencies: 0 Mar 7, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were substantiated.
Report Facts
Residents Served: 61 License Capacity: 80 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 19 Current Hospice Residents: 5 Residents Diagnosed with Mental Illness: 1 Residents Diagnosed with Intellectual Disability: 0 Residents with Mobility Need: 21 Residents with Physical Disability: 1 Residents Age 60 or Older: 61
Inspection Report Complaint Investigation Census: 75 Capacity: 80 Deficiencies: 0 Jul 25, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Report Facts
License Capacity: 80 Residents Served: 75 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 18 Current Hospice Residents: 1 Residents with Mobility Need: 27 Residents Age 60 or Older: 75
Inspection Report Follow-Up Census: 65 Capacity: 80 Deficiencies: 5 Jun 14, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the facility's compliance with previously identified deficiencies and the implementation of the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to resident abuse reporting, notification, incident reporting, and support plan documentation deficiencies. Continued compliance is required.
Deficiencies (5)
Description
Failure to immediately report suspected abuse of a resident to Adult Protective Services.
Failure to immediately notify the resident and the resident’s designated person of a report of suspected abuse or neglect.
Failure to report an incident or condition to the Department’s personal care home regional office within 24 hours.
Resident support plans did not document how needs regarding agitation and confusion would be met.
Residents who participated in the development of their support plans did not sign the support plans.
Report Facts
License Capacity: 80 Residents Served: 65 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 17 Current Hospice Residents: 1 Total Daily Staff: 91 Waking Staff: 68
Inspection Report Complaint Investigation Census: 60 Capacity: 80 Deficiencies: 1 May 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review the facility's compliance with regulatory requirements.
Findings
The submitted plan of correction related to a deficiency in assisting a resident with arranging and tracking podiatry appointments was found to be fully implemented. The facility must maintain continued compliance.
Complaint Details
The inspection was complaint-driven and the submitted plan of correction was accepted and fully implemented as of 07/03/2023.
Deficiencies (1)
Description
The assessment and support plan for resident #1 indicated total assistance was required for arranging and tracking appointments, but the last podiatrist visit arranged by the home was not timely.
Report Facts
License Capacity: 80 Residents Served: 60 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 12 Current Hospice Residents: 1 Residents Age 60 or Older: 60 Residents with Mobility Need: 18 Residents with Physical Disability: 1 Total Daily Staff: 78 Waking Staff: 59
Inspection Report Renewal Census: 60 Capacity: 80 Deficiencies: 11 Apr 11, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including failure to post current license inspection summaries, clutter and hazards in a resident's apartment, unscreened operational windows, incomplete first aid kit supplies, incomplete medical evaluations for residents, and inaccuracies in support plans and signatures. All deficiencies had plans of correction accepted and were implemented by July 17, 2023.
Deficiencies (11)
Description
License Inspection Summaries dated 7/22/22, 11/28/22, and 1/11/23 were not posted in a conspicuous and public place in the home.
Resident #1's apartment was cluttered and not free from hazards with boxes piled 4-5 feet high.
Unscreened operational windows found throughout the home including resident rooms #118, 120, 122, 124, and 159.
First Aid Kit on the crash cart on Wood Side Place did not include gauze.
Resident #2's medical evaluation missing height, weight, temperature, pulse rate, blood pressure, health status, and cognitive functioning assessments.
Resident #3's medical evaluation missing temperature assessment.
Resident #4's medical evaluation missing height, weight, pulse rate, blood pressure, health status, cognitive functioning assessments, and medical professional license number.
Resident #6's support plan did not indicate use of a bedside enabler though one was observed at resident #2's bedside.
Resident #3's support plan did not indicate use of a bedside enabler though one was observed at resident #3's bedside.
Resident #5's support plan did not indicate use of a bedside enabler though one was observed at resident #5's bedside.
Residents #2, #4, #5, and #6 participated in support plan development but had not signed the plans as of the inspection date.
Report Facts
Residents Served: 60 License Capacity: 80 Residents Served in Secured Dementia Care Unit: 14 Capacity of Secured Dementia Care Unit: 24 Residents Age 60 or Older: 60 Residents with Mobility Need: 20
Inspection Report Complaint Investigation Census: 62 Capacity: 80 Deficiencies: 0 Jan 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 80 Residents Served: 62 Secured Dementia Care Unit Capacity: 20 Secured Dementia Care Unit Residents Served: 17 Hospice Residents: 2 Residents Age 60 or Older: 62 Residents Diagnosed with Mental Illness: 33 Residents with Mobility Need: 28 Residents with Physical Disability: 1
Inspection Report Census: 62 Capacity: 80 Deficiencies: 0 Nov 23, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 62 License Capacity: 80 Secured Dementia Care Unit Capacity: 24 Secured Dementia Care Unit Residents Served: 17 Hospice Current Residents: 2 Residents Age 60 or Older: 62 Residents with Mobility Need: 18 Residents with Physical Disability: 1
Inspection Report Complaint Investigation Census: 66 Capacity: 80 Deficiencies: 9 Jul 19, 2022
Visit Reason
The inspection was conducted as a full, unannounced licensing inspection with a provisional and incident reason, including follow-up on a plan of correction.
Findings
Multiple violations were found including a medication error where resident #2 was administered medication prescribed for resident #1, failure to follow prescriber's orders, improper medication documentation, unsafe furniture, improper food storage, and outdated fire safety inspection. The medication error resulted in resident #2's death and staff disciplinary actions were taken.
Complaint Details
The visit was complaint-related due to a medication error involving administration of medication to the wrong resident, resulting in resident #2's death. Staff failed to notify the physician timely and did not follow emergency protocols. Staff members involved were interviewed, suspended, and terminated based on investigation findings.
Deficiencies (9)
Description
Resident #2 was administered Lacosamide 200mg prescribed for resident #1, resulting in adverse health effects and death.
Failure to follow prescriber's orders; resident #1 did not receive prescribed medication as ordered.
Medication administration documentation was inaccurate; medication was documented as given but was not administered.
Furniture and equipment not in good repair; a glass lamp in resident #3's room was in disrepair and unplugged with exposed wiring.
Food not protected from contamination; approximately 100 fruit cups were stored uncovered in the kitchen refrigerator.
Fire safety inspection and fire drill were not conducted annually; last completed on 1/15/2020.
Medication in the home was discontinued but still present in the medication cart.
Controlled medication counts were inaccurate; discrepancy found in narcotic medication count.
Failure to secure medical care appropriately after medication error and resident condition decline.
Report Facts
License Capacity: 80 Residents Served: 66 Staffing Hours: 89 Waking Staff: 67 Medication Error Date: 1 Plan of Correction Completion Dates: 9
Employees Mentioned
NameTitleContext
Staff member AAdministered medication incorrectly and was verbally educated on policies.
Staff member BLicensed staffWas training staff member A, suspended and later terminated following investigation of medication error.
Staff member DFailed to notify physician after resident condition declined; received verbal warning.
Jamie BuchenauerDeputy Secretary, Office of Long-term LivingSigned the licensing letter regarding provisional license issuance.
Inspection Report Renewal Deficiencies: 0 May 3, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report Monitoring Census: 61 Capacity: 80 Deficiencies: 11 Oct 15, 2021
Visit Reason
The inspection was an unannounced partial monitoring visit conducted on 10/15/2021 to assess compliance with Department statutes and regulations.
Findings
Multiple deficiencies were identified including medication administration errors, incomplete training records, unsecured and uncovered bed enablers, sharing of glucometers between residents, lack of thermometer in the kitchen freezer, lint accumulation in laundry dryers, incomplete medical evaluations, inaccurate medication labeling, and medication administration record discrepancies. All deficiencies were corrected immediately or with directed plans of correction.
Deficiencies (11)
Description
Medication error with untimely administration of Tramadol and failure to report the incident to the Department.
Training record titled 'Sanitary conditions' lacked date and length of training.
Uncovered bed enablers with openings and unsecured bed enabler present at residents' beds.
Shared use of glucometer between residents without proper sanitation.
No thermometer present in the home's main kitchen freezer.
Accumulation of lint in the lint trap of the middle dryer in the main laundry room.
Resident medical evaluation updates lacked date, time, person spoken to, and staff initials for corrections.
Pharmacy labels on medications did not match prescribed dosages and schedules.
Medication administration records did not accurately reflect prescribed medication dosages and schedules.
Failure to follow prescriber's orders for multiple residents' medications and incomplete documentation of blood pressure readings.
Medical evaluation for secured dementia care unit lacked proper documentation of updates.
Report Facts
License Capacity: 80 Residents Served: 61 Secured Dementia Care Unit Capacity: 24 Residents Served in Secured Dementia Care Unit: 20 Current Hospice Residents: 1 Resident Mobility Need: 28 Resident Physical Disability: 1 Total Daily Staff: 89 Waking Staff: 67 Medication Administration Errors: 1 Lint Accumulation: 2
Notice Capacity: 80 Deficiencies: 0 Aug 25, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Manchester Commons of Presbyterian Senior Care, a Personal Care Home, and informs that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
The document does not report inspection findings but confirms issuance of a regular license following the renewal application and states that future inspections will be conducted to ensure compliance.
Report Facts
Maximum licensed capacity: 80 Secure Dementia Care Unit capacity: 24
Employees Mentioned
NameTitleContext
Jamie L. BuchenauerDeputy Secretary, Office of Long-term LivingSigned the renewal notification letter
Inspection Report Renewal Census: 58 Capacity: 80 Deficiencies: 12 Jun 9, 2021
Visit Reason
The inspection was a renewal inspection conducted on June 9-11, 2021, to assess compliance with licensing regulations for Manchester Commons of Presbyterian Senior Care.
Findings
The inspection identified multiple violations including medication administration errors, failure to report incidents timely, confidentiality breaches, sanitary and safety issues, missing emergency telephone numbers, improper food storage and labeling, lint accumulation in dryer, incomplete medical evaluations, failure to follow prescriber's orders, and missing resident photographs. Plans of correction were accepted for all violations with some violations later withdrawn.
Deficiencies (12)
Description
Failure to report medication errors to the Department within 24 hours.
Resident records and support plans were unlocked and unattended, breaching confidentiality.
Over 30 cigarette butts found in non-smoking area near kitchen entrance and dumpster.
Trash can in woman's bathroom lacked a lid.
Emergency telephone numbers not posted near telephones in resident bedrooms.
Unlabeled and undated food items found in secured dementia care unit refrigerator.
No thermometer in the secured dementia care unit kitchen freezer.
Food stored uncovered and unsealed in the secured dementia care unit kitchen freezer.
Accumulation of lint and dryer sheets in dryer lint trap and ductwork.
Medical evaluations updated without proper documentation of date, time, and person spoken to.
Medications not administered according to prescriber's orders for residents #3 and #4.
Resident record missing a photograph no more than 2 years old.
Report Facts
License Capacity: 80 Residents Served: 58 Residents in Secured Dementia Care Unit: 17 Capacity of Secured Dementia Care Unit: 24 Current Hospice Residents: 2 Staffing Hours - Total Daily Staff: 79 Staffing Hours - Waking Staff: 59 Fine Amount: 183 Mandated Correction Date: 15

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