Pennsylvania Department of Health
SPIRITRUST LUTHERAN THE VILLAGE AT GETTYSBURG
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SPIRITRUST LUTHERAN THE VILLAGE AT GETTYSBURG - 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 May 28, 2024, at Spiritrust Lutheran the Village at Gettysburg, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #124402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 28, 2024, it was determined that Spiritrust Lutheran the Village at Gettysburg 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 two-story, Type III (211), protected ordinary structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. 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. This deficiency was not found to be throughout this facility.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain delayed egress signage for special locking arrangements, in two of ten smoke zones within the component.

Findings include:

1. Observation on May 28, 2024, between 12:00 PM and 12:30 PM, revealed the exit discharge doors lacked delayed egress signage, at the following locations:

a. 12:00 PM, 2nd floor Stairtower Door #2A56B, by Nurses' Station;
b. 12:30 PM, 2nd floor Stairtower Door #2B54, by Lounge.

Interview with the Executive Director, Director of Facilities and Facilities Supervisor on May 28, 2024, at 1:45 PM, confirmed exit doors lacked signage for the special locking arrangements.

Plan of Correction - To be completed: 06/28/2024

Proper signage will be installed on stair tower doors 2A56B and 2B54 to indicate 15 second delayed egress. Documentation will be updated for the weekly testing of the locking arrangements to include the visual inspection confirming that signage is in place, and in good condition. Updated documentation will be presented to QAPI for evaluation.

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 provide tri-annual documentation, maintain the automatic sprinkler piping system, to be free of extraneous weight, and sprinkler heads, to be free from obstruction, affecting ten of ten smoke compartments within the component.

Findings include:

1. Review of documentation and observation on May 6, 2024, between 9:30 AM and 11:15 AM, revealed the facility lacked documentation, verifying the dry system 3-year full flow trip test was performed.

Interview at the time of the exit conference with the Director of Nursing and Director of Environmental Services on May 14, 2024, at 1:45 PM, confirmed the facility could not provide the 3-year dry system full trip test.

2. Observation on May 28, 2024, at 12:45 PM, revealed corridor 1A cross section, above the ceiling, had multiple wires and hard ducting laying on the drop ceiling grid and tied to the sprinkler piping system.

Interview at the time of the exit conference with the Director of Nursing and Director of Environmental Services on May 14, 2024, at 1:45 PM, confirmed various items being supported by sprinkler piping system.

3. Observation on May 28, 2024, between 1:10 PM and 1:14 PM, revealed sprinkler heads were subject to a load of debris, at the following locations:

a. 1:10 PM, Laundry Room, Washroom 1 sprinkler head;
b. 1:14 PM, Laundry Room, Folding Room 1 sprinkler head.

Interview at the time of the exit conference with the Director of Nursing and Director of Environmental Services on May 14, 2024, at 1:45 PM, confirmed sprinkler heads were carrying an accumulated load of debris.

Plan of Correction - To be completed: 06/28/2024

1. Documentation from the inspection conducted May 9, 2024 by Susquehanna Automatic Sprinkler Inc. confirmed that the dry system full flow trip test was performed. However, the documentation does not include that this is to be completed every three years. The incomplete information will be presented to SASI for revision of the documentation submitted after every inspection. This update will be presented to QAPI for evaluation. A quarterly work order will be created to review the documentation in the Life Safety binder to confirm it is up to date and includes the correct information. This correction will be completed by June 28, 2024.
2. Data wiring, metal ductwork, and ceiling grid wire will be adjusted or removed from coming in contact with sprinkler piping above the 1A corridor intersection. A recurring work order will be created to confirm that this piping is free from supporting any foreign objects, and will be performed every quarter for one year. Completed work order documentation will be presented to QAPI for evaluation. This corrective action will be completed by June 28, 2024.
3. Debris will be removed from the sprinkler heads in the washer room and folding room of our laundry department. Cleaning the sprinkler heads in this department will be added to the recurring work order of cleaning the dryers, which is conducted quarterly. Completed work order documentation will be presented to QAPI for evaluation. This correction will be completed by June 28, 2024.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors, to self-close, affecting two of ten smoke compartments within the component.

Findings include:

1. Observation on May 28, 2024, at 12:05 PM, revealed the double smoke barrier door, #2A50 in the Arlington Corridor, with latching hardware, did not close and latch.

Interview with the Executive Director, Director of Facilities and Facilities Supervisor on May 28, 2024, at 1:45 PM, confirmed the doors did not self-close.

Plan of Correction - To be completed: 06/28/2024

Susquehanna Door Service has been contracted to complete repairs to the smoke barrier door 2A50 at the entrance to Braeburn Lounge from the Arlington corridor. A recurring work order will be created to confirm that this door properly closes, hardware positively latches, and maintains proper gaps. This work order will be performed quarterly and will also mirror the current door inspection procedures and documentation. This information will be presented to QAPI for evaluation. This corrective active will be completed by June 28, 2024.

NFPA 101 STANDARD Electrical Systems - Receptacles:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. 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.

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain power receptacles, to be Ground Fault Interruption (GFI) protected within six feet of a water source, in one of ten smoke compartments within the component.

Findings include:

1. Observation on May 28, 2024, between 11:50 AM and 11:53 AM, revealed outlets were not GFI protected and within six feet of a water source, at the following locations:

a. 11:50 AM, 2nd floor, Ellison Hall, Nurses' Station/Activities Room, behind refrigerator 1;
b. 11:53 AM, 2nd floor, Ellison Hall, Nurses' Station/Activities Room, by stove 1.

Interview with the Executive Director, Director of Facilities and Facilities Supervisor on May 28, 2024, at 1:45 PM, confirmed outlets were not GFI protected.

Plan of Correction - To be completed: 06/28/2024

GFI receptacles will be installed for the refrigerator and beside the range in the Ellison Activities Room. A recurring work order will be generated to inspect these receptacles for proper operation and tripped for testing. This work order will be performed quarterly and will also include the existing GFI closest to the sink. A one time facility wide audit to identify any other outlets that need to be GFI corrected will be completed. Completed documentation will be presented to QAPI for evaluation. This corrective action will be completed by June 28, 2024.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

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, readily identifiable, and separate from normal power circuits. 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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide test results of the annual fuel quality sample performed, for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on May 28, 2024, between 9:30 AM and 11:15 AM, revealed the facility could not provide the test results of the fuel quality sample taken for the emergency generator, within the previous twelve months.

Interview with the Executive Director, Director of Facilities and Facilities Supervisor on May 28, 2024, at 1:45 PM, confirmed the facility could not provide the test results.

Plan of Correction - To be completed: 06/28/2024

Winter's Generator Service will take a fuel sample from the main generator for quality testing. They will be asked to include this during their annual four hour load testing, and include it with their documentation submitted. A quarterly work order will generate to review and maintain this documentation in the Life Safety binder. This information will be presented to QAPI for evaluation. This corrective action will be completed by June 28, 2024.

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