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 June 11, 2024, 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 June 11, 2024, 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 General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation and interview on June 11, 2024, between 8:45 AM and 10:15 AM, revealed the facility portable life safety drawings did not identify resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas and compartment designation.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the life safety drawings did not provide all the information needed to complete a life safety survey.

2. Review of documentation and interview on June 11, 2024, between 8:45 AM and 10:15 AM, revealed the facility lacked documentation of annual testing and inspection of installed Carbon Monoxide Detectors per manufacturer's instructions, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act, for the following:

a. outlet/battery-operated carbon monoxide detectors;
b. carbon monoxide, installed and independent of the fire alarm system.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the annual inspections were not performed per manufacture's specifications and NFPA 72.

Plan of Correction - To be completed: 08/01/2024

1. The mentioned portable life safety drawings do identify resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas and compartment designation. Manufacturers instructions for the carbon monoxide detectors have been obtained and annual inspection has been completed for the outlet/battery-operated carbon monoxide detectors and the carbon monoxide detectors installed and independent of the fire system.
2. The NHA/Designee will provide education to the Maintenance Department to include the location of the portable life safety drawings and maintaining the manufacturer's instructions for the carbon monoxide detectors.
3. Audits will be completed every 6 months for location and availability of the life safety drawings and the yearly testing of the carbon monoxide detectors. The results of the findings will be reported at the facility Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

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, observation, and interview, it was determined the facility failed to provide documentation of an approved fire alarm system upgrade, and could not verify a 2-year sensitivity test had been performed, which serves the entire component.

Findings include:

1. Review of documentation, observation, and interview on June 11, 2024, between 8:45 AM and 10:15 AM, revealed on March 11, 2024, the facility installed a new fire alarm panel, but could not provide a Department of Health approved plan.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed a new fire alarm panel installed without prior approval from the Pennsylvania Department of Health.

2. Review of documentation on June 11, 2024, between 8:45 AM and 10:15 AM, revealed the facility failed to provide documentation verifying a 2-year sensitivity test of the smoke detectors had occurred, within the previous two years.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the facility could not provide documentation for the 2-year sensitivity test.

Plan of Correction - To be completed: 08/01/2024

1. The facility will submit plans for the fire alarm panel to the Department of Health Life Safety Plan review seeking approval. The 2-year sensitivity test of the smoke detectors, dated 4/6/2023, was re-sent to the life safety inspector and is available on the premises.
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 and to maintain records of 2-year sensitivity tests of the smoke detectors on the premises.
3. Upgrades and changes will be reviewed prior to making the upgrades and changes to ensure plans have been submitted to the Department of Health for approval. Audits will be completed every six months to ensure inspections are up to date, reports have been received, any recommended repairs or upgrades have been completed, and future inspections are scheduled as required. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 5-year sprinkler maintenance documentation, maintain the sprinkler piping system to be free of extraneous weight, and sprinkler heads to be free from obstruction, affecting three of four smoke compartments within the component.

Findings include:

1. Review of documentation on June 11, 2024, between 9:20 AM and 9:22 AM, revealed the facility lacked documentation, for the following:

a. 9:20 AM, 5-year internal pipe and valve inspection;
b. 9:22 AM, 5-year gauge replacement/calibration.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the facility could not provide documentation of the 5 year testing and inspections.

2. Observation on June 11, 2024, between 10:50 AM and 11:15 AM, revealed multiple wires laying on and/or tied to sprinkler piping system, at the following locations:

a. 10:50 AM, Housekeeping Corridor;
b. 10:55 AM, 200 Hall, above ceiling, by Resident Room 207;
c. 11:15 AM, Supervisor Nursing Station.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed there were various items attached and laying on the sprinkler pipes.

3. Observation on June 11, 2024, between 11:50 AM and 11:55 AM, revealed sprinkler heads covered with debris, at the following locations:

a. 11:50 AM, Laundry Room, Dryer Chase Room, 2 sprinkler heads;
b. 11:52 AM, Laundry Room, Chemical Room, 1 sprinkler head;
c. 11:55 AM, Laundry Room, Washer Room, 1 sprinkler head.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed debris covering sprinkler heads.

Plan of Correction - To be completed: 08/01/2024

1. The mentioned wires were removed from the sprinkler piping above the suspended ceiling. The sprinkler heads covered with debris were cleaned. The facility scheduled the 5-year internal pipe and valve inspection and the 5-year gauge replacement/calibration inspection.
2. The NHA/Designee will provide education to the Maintenance Department to include the automatic sprinkler protection system to be free from extraneous weight, and to maintain documentation of internal pipe and valve and gauge replacement/calibrations and to keep sprinkler heads free from debris.
3. Five random audits above the suspended ceiling will be completed each week for eight weeks by the Maintenance Director/Designee to ensure there is nothing resting on the sprinkle piping. Yearly audits for retention and availability of the 5-year internal pipe and valve inspection and the 5-year gauge replacement/calibration inspection will be completed by the Maintenance Manager/Designee. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Utilities - Gas and Electric:

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.

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain electrical hardware components to be complete, affecting two of five smoke compartments within the component.

Findings include:

1. Observation on June 11, 2024, between 11:05 AM and 11:17 AM, revealed electrical junction boxes without a cover plate, at the following locations:

a. 11:05 AM, 200 Hall, above ceiling, by Resident Room 207;
b. 11:17 AM, Supervisor Nursing Station, above ceiling.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the junction boxes did not have a cover plate installed.

Plan of Correction - To be completed: 08/01/2024

1. The mentioned electrical junction boxes above the suspended ceiling have been repaired to add a cover plate and will be audited for completion.
2. The NHA/Designee will provide education to the Maintenance Department that includes electrical hardware components are to be complete and are to include a cover plate to electrical junction boxes.
3. Five random audits above the suspended ceiling will be completed each week for eight weeks by the Maintenance Manager/Designee to ensure that electrical hardware is maintained and completed. 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:

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 June 11, 2024, between 8:45 AM and 10:15 AM, revealed the facility relied on a temporary generator for at least the previous twenty-one months and has not demonstrated progress in the acquisition of a permanent emergency electrical system, since August 2022.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the reliance upon a temporary generator, for more than 90 days.

2. Review of documentation on June 11, 2024, between 8:45 AM and 10:15 AM, revealed the facility failed to submit the following items, in regards to the temporary generator:

a. 8:45 AM, facility failed to submit documents for the temporary generator to Plan Review, to allow the current temporary generator to remain in place;
b. 10:15 AM, facility failed to provide documentation indicating a replacement generator has been sourced and reserved for the facility.

Exit interview with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 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.

3. Review of documentation on June 11, 2024, between 9:50 AM and 9:52 AM, revealed the facility lacked documentation for the following:

a. 9:50 AM, Fuel Quality Letter;
b. 9:52 AM, annual 90-minute load test.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the facility could not provide the documentation of the required testing.

Plan of Correction - To be completed: 08/01/2024

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. The facility is obtaining a Fuel Quality Letter and has performed an annual 90-minute load test.
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 and to maintain records a Fuel Quality Letter on the premises and perform and maintain documentation of annual 90-minute generator load testing.
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. Semi-annual audits for required testing and for retention and availability of Fuel Quality Letters and 90-minute load tests along with audits of building systems for any upgrades the may be required to report for plan review will be completed by the Maintenance Manager/Designee. 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 June 11, 2024, 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 General Requirements - Other:

Observations:
Name: THERAPY ADD - Component: 02 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation and interview on June 11, 2024, between 8:45 AM and 10:15 AM, revealed the facility portable life safety drawings did not identify resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas and compartment designation.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the life safety drawings did not provide all the information needed to complete a life safety survey.

Plan of Correction - To be completed: 08/01/2024

1. The mentioned portable life safety drawings do identify resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas and compartment designation. Manufacturers instructions for the carbon monoxide detectors have been obtained and annual inspection has been completed for the outlet/battery-operated carbon monoxide detectors and the carbon monoxide detectors installed and independent of the fire system.
2. The NHA/Designee will provide education to the Maintenance Department to include the location of the portable life safety drawings and maintaining the manufacturer's instructions for the carbon monoxide detectors.
3. Life safety drawings will be audited every 6 months for location and availability. The results of the findings will be reported at the facility Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Observations:
Name: THERAPY ADD - Component: 02 - Tag: 0345

Based on document review, observation, and interview, it was determined the facility failed to provide documentation of an approved fire alarm system upgrade, and could not verify a 2-year sensitivity test had been performed, which serves the entire component.

Findings include:

1. Review of documentation, observation, and interview on June 11, 2024, between 8:45 AM and 10:15 AM, revealed on March 11, 2024, the facility installed a new fire alarm panel, but could not provide a Department of Health approved plan.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed a new fire alarm panel installed without prior approval from the Pennsylvania Department of Health.

2. Review of documentation on June 11, 2024, between 8:45 AM and 10:15 AM, revealed the facility failed to provide documentation verifying a 2-year sensitivity test of the smoke detectors had occurred, within the previous two years.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the facility could not provide documentation for the 2-year sensitivity test.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: THERAPY ADD - Component: 02 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide 5-year sprinkler maintenance documentation and maintain the sprinkler piping system, to be free of extraneous weight, affecting one of one smoke compartments within the component.

Findings include:

1. Review of documentation on June 11, 2024, between 9:20 AM and 9:22 AM, revealed the facility lacked documentation, for the following:

a. 9:20 AM, 5-year internal pipe and valve inspection;
b. 9:22 AM, 5-year gauge replacement/calibration.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the facility could not provide documentation for the five year testing and inspections.

2. Observation on June 11, 2024, at 10:40 AM, revealed multiple wires and flex ducting laying on sprinkler piping system, above ceiling, by the Soiled Utility Room door.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed multiple items on the sprinkler piping system.

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 June 11, 2024, between 8:45 AM and 10:15 AM, revealed the facility relied on a temporary generator for at least the previous twenty-one months and has not demonstrated progress in the acquisition of a permanent emergency electrical system, since August 2022.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the reliance upon a temporary generator, for more than 90 days.

2. Review of documentation on June 11, 2024, between 8:45 AM and 10:15 AM, revealed the facility failed to submit the following items, in regards to the temporary generator:

a. 8:45 AM, facility failed to submit documents for the temporary generator to Plan Review, to allow the current temporary generator to remain in place;
b. 10:15 AM, facility failed to provide documentation indicating a replacement generator has been sourced and reserved for the facility.

Exit interview with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 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.

3. Review of documentation on June 11, 2024, between 9:50 AM and 9:52 AM, revealed the facility lacked documentation for the following:

a. 9:50 AM, Fuel Quality Letter;
b. 9:52 AM, annual 90-minute load test.

Interview at the time of the exit conference with the Director of HR, Maintenance Director and Director of Nursing on June 11, 2024, at 1:45 PM, confirmed the facility could not provide the documentation of the required testing.

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