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

There are 39 surveys for this facility. Please select a date to view the survey results.

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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 March 5, 2024, at Gettysburg Center, 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 #078502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 5, 2024, 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 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 observation 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. Observation on March 5, 2024, at 11:30 AM, revealed the facility failed to provide accurate and complete floor plans for the facility.
Interview with the Director of Maintenance on March 5, 2024, at 11:30 AM, confirmed the plans provided were incorrect.

Plan of Correction - To be completed: 04/15/2024

Accurate floor plans have been obtained.

These plans are placed in the life safety book for future surveys.

Maintenance team educated about floor plans and where they are maintained.

Maintenance director and administrator will review floor plans to make sure they are submitted and maintained in the book throughout the year. These will be reviewed at QAPI.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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.

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be within the allowable gap margins, in one of six smoke compartments within the component.

Findings include:

1. Observation on March 5, 2024, at 12:30 PM, revealed the clean side Laundry Room door had gaps greater than 3/16 inch.

Interview with the Director of Maintenance on March 5, 2024, at 12:30 PM, confirmed the hazardous area door exceeded the allowed gap margins.

Plan of Correction - To be completed: 04/15/2024

1) Laundry Room door was redone by the contractor on March 15th, 2024 under warranty so that gaps did not exceed 3/16th of an inch.
2) All other doors were checked to make sure that they did not exceed the required gap.
3) Maintenance team reeducated about gap requirements and double checking contractor work.
4) Maintenance director or designee will audit gaps monthly to ensure that they meet gap requirements for three months. These audits will be reviewed at QAPI.

NFPA 101 STANDARD Corridor - Doors:

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, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on March 5, 2024, at 2:00 PM revealed the Main Dining Room double corridor doors, inactive leaf, automatic flush bolt failed to positively latch.

Interview with the Director of Maintenance on March 5, 2024, at 2:00 PM, confirmed the doors lacked positive latching.

Plan of Correction - To be completed: 04/15/2024

1) Main Dining Room door was corrected so that the automatic flush bolt positively latches.
2) All other corridor doors were checked to make sure that they positively latched.
3) Maintenance team reeducated about the requirements of positively latching corridor doors and the necessity to routinely check them.
4) Maintenance director or designee will audit corridor doors latching monthly throughout year and report the findings at QAPI.

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