Pennsylvania Department of Health
GARDENS AT GETTYSBURG, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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GARDENS AT GETTYSBURG, THE - 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 20, 2025, at The Gardens 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 #132802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 20, 2025, it was determined that The Gardens 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 one-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Corridor - Doors:

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.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, in one of five smoke compartments within the component.

Findings include:

1. Observation on May 20, 2025, at 1:45 PM, revealed the corridor door to Resident Room 412 was hitting the frame and failed to positively latch in the frame.

Interview with the Administrator and the Director of Maintenance on May 20, 2025, at 1:45 PM, confirmed the door was hitting the frame and failed to latch in its frame.

Plan of Correction - To be completed: 06/25/2025

1. The mentioned door has been repaired to no longer hit the frame and allow positive latching into the frame when closing.
2. The NHA/Designee will provide education to the Maintenance Department and facility staff to understand the Life Safety regulation that doors are not to have impediment from closing and must positively latch within the door frame.
3. Ten random audits for positive latching doors will be completed each week for eight weeks by the Maintenance Director/Designee to ensure corridor doors are positively latching within the door frame. Monthly audits will continue to be conducted to ensure doors positively latch within the door frame. The results of the findings will be reported monthly at the Facility Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0915

Based on document review, observation and interview, it was determined the facility failed to provide a permanent emergency electrical system and maintenance documentation, affecting the entire component.

Findings include:

1. Review of documentation and observation on May 20, 2025, between 10:00 AM and 11:15 AM, revealed the facility relied on a temporary generator for at least the previous thirty-one months and has not demonstrated progress in the acquisition of a permanent emergency electrical system, since August 2022.

Interview at the time of exit with the Administrator and the Director of Maintenance on May 20, 2025, at 2:15 PM, confirmed the reliance upon a temporary generator, for more than 90 days.

2. Review of documentation on May 20, 2025, between 10:00 AM and 11:15 AM, revealed the facility failed to submit the following items, in regards to the temporary generator:

a. 10:00 AM, facility failed to submit documents for the temporary generator to Plan Review, to allow the current temporary generator to remain in place;
b. 10:45 AM, facility failed to provide documentation indicating a replacement generator has been sourced and reserved for the facility.

Interview at the time of exit with the Administrator and the Director of Maintenance on May 20, 2025, at 2:15 PM, confirmed the facility failed to seek plan approval to use a temporary electrical system, longer than 90 days, and to pursue acquisition of a permanent replacement.

Plan of Correction - To be completed: 06/25/2025

1. The facility will submit plans to the Department of Health Life Safety Plan review seeking approval for use of a temporary generator for a period longer than 90 days. The facility will consult with an Architect/ Mechanical Engineer to develop plans for the purchase and installation of a new generator in accordance with NFPA 110 Standards.
2. The NHA/Designee will provide education to the Maintenance Department to include the submission for plan review to the department of health for any upgrades or changes in the facility.
3. Upgrades and changes will be reviewed prior to making the upgrades and changes to ensure a plan review have been submitted to the Department of Health for approval. The Maintenance Manager/Designee will have the plans reviewed by the NHA prior to submission to Life Safety Plan Review. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvement meeting.

Initial comments:Name: THERAPY ADD - Component: 02 - Tag: 0000

Facility ID #132802
Component 02
Therapy Addition

Based on a Medicare/Medicaid Recertification Survey completed on May 20, 2025, it was determined that The Gardens 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: THERAPY ADD - Component: 02 - Tag: 0915

Based on document review, observation and interview, it was determined the facility failed to provide a permanent emergency electrical system and maintenance documentation, affecting the entire component.

Findings include:

1. Review of documentation and observation on May 20, 2025, between 10:00 AM and 11:15 AM, revealed the facility relied on a temporary generator for at least the previous thirty-one months and has not demonstrated progress in the acquisition of a permanent emergency electrical system, since August 2022.

Interview at the time of exit with the Administrator and the Director of Maintenance on May 20, 2025, at 2:15 PM, confirmed the reliance upon a temporary generator, for more than 90 days.

2. Review of documentation on May 20, 2025, between 10:00 AM and 11:15 AM, revealed the facility failed to submit the following items, in regards to the temporary generator:

a. 10:00 AM, facility failed to submit documents for the temporary generator to Plan Review, to allow the current temporary generator to remain in place;
b. 10:45 AM, facility failed to provide documentation indicating a replacement generator has been sourced and reserved for the facility.

Interview at the time of exit with the Administrator and the Director of Maintenance on May 20, 2025, at 2:15 PM, confirmed the facility failed to seek plan approval to use a temporary electrical system, longer than 90 days, and to pursue acquisition of a permanent replacement.

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