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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SPIRITRUST LUTHERAN THE VILLAGE AT UTZ TERRACE
Inspection Results For:

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SPIRITRUST LUTHERAN THE VILLAGE AT UTZ TERRACE - 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 11, 2023, at Spiritrust Lutheran the Village at Utz Terrace, 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 #17620201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 11, 2023, it was determined that Spiritrust Lutheran the Village at Utz Terrace had deficiencies that have the potential for minimal harm as related to 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 Portable Fire Extinguishers:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to maintain documentation verifying portable fire extinguishers had been subjected to monthly inspections during the previous twelve months, affecting one of three smoke compartments within the component.

Findings include:

1. Review of documentation on May 11, 2023, at 11:05 AM, revealed the facility lacked documentation verifying the portable fire extinguisher located within the Beauty Salon had been inspected since March 19, 2023.

Interview with the Director of Facilities on May 11, 2023, at 11:05 AM, confirmed the facility lacked documentation verifying the portable fire extinguisher had been inspected since March 19, 2023.




 Plan of Correction - To be completed: 06/12/2023

The statement/s made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency/s herein.

To remain in compliance with all Federal and State regulations, the facility has taken, and will continue to take the actions set forth in the following plan of correction.

The following plan of correction constitutes the center's allegation of compliance. The alleged deficiency cited has been / or will be corrected by the date/s indicated.

The facility is committed to taking all actions necessary to remain in substantial compliance with the Federal and State regulations.

The plan of correction addresses our intentions to promote care/safety for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psycho-social well-being.

No residents were affected by this deficiency.

The Director of Buildings and Grounds (B&G) verified all remaining portable fire extinguishers were subjected to monthly inspections during the previous months.

Monthly inspections of the portable fire extinguishers are routinely performed by the community's Security Staff and will continue to be inspected monthly.

The Director of B&G and/or designee will in-service the B&G staff, as well as the security staff, on NFPA 101 Portable Fire Extinguishers related to the monthly inspection requirements and the documentation required to support verification of said inspections.

The Director of B&G and/or designee will perform one documented random weekly audit for one month, then 2 documented random audits per month for two months for monthly inspection verification/compliance.

Following the documented random audits over the next three months, the Director of B&G and/or designee will perform one quarterly random audit for inspection verification/compliance, each quarter, through the remainder of the fiscal year.

The results of the audits will be submitted to the QAPI committee monthly, for three months, for review and determination of need for further action as needed.


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