Pennsylvania Department of Health
SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE
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 LUTHER RIDGE - 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 13, 2025, at Spiritrust Lutheran the Village at Luther Ridge, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID #25750201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 13, 2025, it was determined that Spiritrust Lutheran the Village at Luther Ridge was not in compliance with the following requirements of the Life Safety Code for a new 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, which is fully sprinklered.

Plan of Correction:

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: SNF BUILDING - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, which serves the entire component.

Findings include:

1. Observation on May 13, 2025, at 11:30 AM, revealed the fire alarm system lacked the semi-annual inspection. The last inspection was performed on June 24, 2024.

Interview with the Adminstrator and the Director of Building and Grounds, at 11:30 AM, confirmed the fire alarm system lacked the semi-annual inspection, for the month of December 2025.

Plan of Correction - To be completed: 06/20/2025

1. The semi-annual fire alarm system inspection has been scheduled.
2. The inspection is scheduled for June 17th.
3. This is a semi-annual requirement and audits being conducted will confirm that the next inspection has been scheduled and the last inspection paperwork has been filed in the life safety book.
4. The audits performed will be reviewed at QAPI and evaluated for the need for further interventions.

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