Pennsylvania Department of Health
GETTYSBURG CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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GETTYSBURG CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on February 11, 2026, it was determined that Gettysburg Center was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:
Name: - Component: -- - Tag: 0006 Based on document review and interview, it was determined the facility did not include a documented, facility-based and community-based risk assessment, which affects the entire component. Findings include: 1. Review of documentation on February 11, 2026, at 1:30 PM revealed the facility did not have a complete community-based risk assessment included in the Emergency Preparedness Plan. Plan lacked risk assessment ratings. Interview at the time of the exit conference with the Administrator and Director of Maintenance February 11, 2026, at 1:30 PM, confirmed the facility failed to provide a complete community-based risk assessment.

Plan of Correction - To be completed: 03/24/2026

The facility's Emergency Preparedness Plan will include a community-based risk assessment including all risks and completed by a facility committee.
The facility's committee will be re-educated on completing a community-based risk assessment within the Emergency Preparedness Plan.
The facility will review the Emergency Preparedness Plan every year in order to be certain that the risk assessment was completed and is accurate. Results will be reported to QAPI.

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #078502Component 01Main Building Based on a Medicare/Medicaid Recertification Survey completed on February 11, 2026, it was determined that Gettysburg Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a). This is a one-story, Type II (222), fire resistive structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291 Based on observation and interview, it was determined the facility lacked installed battery back-up lighting at the emergency generator, affecting the entire component. Findings include: 1. Observation and interview on February 11, 2026, at 11:20 AM, revealed the facility lacked installed battery back-up emergency lighting, at the emergency generator. Interview at the time of the exit conference with the Administrator and Director of Maintenance on February 11, 2026, at 1:30 PM,confirmed the facility lacked installed battery back-up lighting, at the emergency generator.

Plan of Correction - To be completed: 03/24/2026

A battery back-up light will be installed at the Emergency Generator.
Maintenance staff will be re-educated on the need for a back-up battery operated light at the emergency generator.
Maintenance staff will audit the battery back-up light at the emergency generator monthly x 3 months to ensure it is functioning. Audits will be reviewed at QAPI.

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.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to perform a bi-annual sensitivity test of the smoke detectors, affecting the entire component. Findings include: 1. Review of documentation and interview on February 11, 2026, between 8:15 AM and 10:45 AM, revealed the facility failed to perform a sensitivity test, in the past two years. Pletcher Fire Protection on 9/10/2025 stated they were unable to perform smoke detector sensitivity test on 90% of the vertical-mounted smoke heads. No other documentation of previous sensitivity was provided. Interview at the time of the exit conference with the Administrator and Director of Maintenance on February 11, 2026, at 1:30 PM, confirmed the facility failed to perform the bi-annual sensitivity test.

Plan of Correction - To be completed: 03/24/2026

A bi-annual sensitivity test of the smoke detectors will be completed.
Maintenance staff will be re-educated by the NHA or designee on the need to have a bi-annual sensitivity test of the smoke detectors.
An audit will be conducted annually to make sure that a sensitivity test was completed on the smoke detectors,
Audits will be reviewed at QAPI.

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 - Component: 01 - Tag: 0353 Based on document review, observation, and interview, it was determined the facility failed to perform 5-year inspections, and maintain the automatic sprinkler system to be free from extraneous weight, in seven of seven smoke zones within the component. Findings include: 1. Review of documentation and interview on February 11, 2026, between 8:40 AM and 8:43 AM, revealed the facility failed to perform the following inspections: a. 8:40 AM, 5-year internal pipe inspection; b. 8:43 AM, 5-year internal valve inspection. Interview at the time of the exit conference with the Administrator and Director of Maintenance February 11, 2026, at 1:30 PM, confirmed the facility failed to perform testing and maintenance on the installed wet sprinkler systems. 2. Observation on February 11, 2026, at 11:52 AM revealed rigid conduit being supported by the sprinkler system, above ceiling, South nurse station. Interview at the time of the exit conference with the Administrator and Director of Maintenance February 11, 2026, at 1:30 PM, confirmed rigid conduit supported by the sprinkler system.

Plan of Correction - To be completed: 03/24/2026

A 5 year inspection will be completed on the sprinkler system and the conduit will not be supported by the sprinkler system.
Maintenance staff will be re-educated on the need to complete a 5 year sprinkler inspection and conduit cannot be supported by the sprinkler system.
An audit will be completed 2 times per year to ensure that the 5 year sprinkler inspection was completed and conduit is not being supported by the sprinkler system when work is completed in the ceiling. Audits will be reported to QAPI.

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