Pennsylvania Department of Health
SPIRITRUST LUTHERAN THE VILLAGE AT SPRENKLE DRIVE
Building Inspection Results

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

There are  35 surveys for this facility. Please select a date to view the survey results.

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SPIRITRUST LUTHERAN THE VILLAGE AT SPRENKLE DRIVE - 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 January 16, 2024, at Spiritrust Lutheran the Village at Sprenkle Drive, 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 #015902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 16, 2024, it was determined that Spiritrust Lutheran the Village at Sprenkle Drive 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, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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

Based on observation and interview, it was determined the facility failed to maintain installed Carbon Monoxide detectors required for carbon monoxide testing and inspection, in accordance with the 2016 Act 48- Care Facility Carbon Monoxide Alarms Act, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on January 16, 2024, at 2:00 PM, revealed the installed Carbon Monoxide detector in the Kitchen failed to operate and had a expiration date of August 2021.

Interview at the time of the exit conference with the Administrator, Director of Facilities and Building and Grounds Supervisor on January 16, 2024, at 2:45 PM, confirmed the Carbon Monoxide detector failed to work.



 Plan of Correction - To be completed: 03/13/2024

The mentioned Carbon Monoxide detector was replaced.

Director of Facilities or designee will educate the maintenance team members on Carbon Monoxide policy and necessary audit documentation.

Director of Facilities or designee will create a list of all Carbon Monoxide detectors in the facility. All detectors will be tested weekly and recorded on the designated audit form.

NHA or designee will review the audit weekly to ensure testing is completed, batteries are replaced, and detectors are working properly for three months, then quarterly x1 year. Findings will be reviewed at QAPI for further evaluation and recommendations.
NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the rated horizontal fire doors to close and latch within the frame, in two of six smoke compartments within the component.
Findings include:
1. Observation on January 16, 2024, between 1:30 PM and 2:32 PM, revealed multiple horizontal fire-rated access doors failed to self-close and latch in the frame, at the following locations:
a. 1:30 PM, 1st floor, Dining Storage Closet;
b. 2:32 PM, 1st floor, Laundry Room.

Interview at the time of the exit conference with the Administrator, Director of Facilities, and Building and Grounds Supervisor on January 16, 2024, at 2:45 PM confirmed the horizontal fire-rated access doors would not self-close and latch.



 Plan of Correction - To be completed: 03/13/2024

The mentioned horizontal access fire doors will be replaced. Replacement and installation will be completed upon receipt of doors, but no later than 14 days after receipt.


Facilities Director or designee will complete a monthly audit for 3 months, then quarterly x1 year audit of all horizontal access doors ensuring self-closure and positive latch within the frame.


NHA or designee will review the audit log monthly to ensure no concerns with door closure and latching for three months, then quarterly x 1 year. Findings will be reviewed at QAPI for further evaluation and recommendations.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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 positively latch, in one of six smoke zones within the component.

Findings include:

1. Observation on January 16, 2024, at 2:30 PM, revealed the Laundry Room door right leaf failed to close and positively latch in frame, due to failed coordinator.

Interview at the time of the exit conference with the Administrator, Director of Facilities and Building and Grounds Supervisor on January 16, 2024, at 2:45 PM confirmed the Laundry Room door failed to close and latch in the frame.



 Plan of Correction - To be completed: 03/13/2024

Director of Facilities ordered new coordinators and will replace the failed coordinator on the mentioned door upon receipt but not later than 14 days.

Recent audit completed of all hazardous areas; no additional concerns revealed.

Director of Facilities or designee will complete a weekly audit for 3 months, then monthly x 1 year of all hazardous area doors to ensure positive latch.

NHA or designee will review the weekly audit for three months, then quarterly x1 year. Findings will be reviewed at QAPI for further evaluation and recommendations.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 and interview, it was determined the facility failed to provide documentation verifying a two year sensitivity test had been performed., affecting the entire component.

Findings include:

1. Review of documentation on January 16, 2024, between 10:45 AM and 12:00 PM, revealed the facility failed to provide documentation verifying a sensitivity test of the smoke detectors had occurred within the previous two years.

Interview at the time of the exit conference with the Administrator, Director of Facilities and Building and Grounds Supervisor on January 16, 2024, at 2:45 PM, confirmed the facility could not provide documentation for the two year sensitivity test.



 Plan of Correction - To be completed: 02/01/2024

The facility had sensitivity test completed on 1/26/24 and 1/30/24.

The Director of Facilities and Johnson Controls will schedule a sensitivity test for every two years annual recurrence.

NHA or designee with review scheduled testing with the Director of Facilities or designee for the facility to ensure necessary sensitivity test is or will be completed every 2 years. Findings will be reviewed at QAPI for further evaluation and recommendations.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide required testing documentation of the annual load bank for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on January 16, 2024, between 10:45 AM and 12:00 PM, revealed the facility lacked documentation that the generator monthly run reaches and did not provide an annual load bank test demonstrating 30 percent or greater of the generator capacity.

Interview at the time of the exit conference with the Administrator, Director of Facilities and Building and Grounds Supervisor on January 16, 2024, at 2:45 PM, confirmed the lack of documentation for the annual load bank.





 Plan of Correction - To be completed: 03/13/2024

The annual load test was completed on 12/26/23, documentation from vendor will be clarified to outline necessary details of the test. Contract with vendor was reviewed, annual load test is included. NHA spoke with generator vendor and DOH-DLS J.D. Sprenkle Drive current testing under EES load is meeting the intent of the code. Director of Facilities will maintain documentation of such.

Director of Facilities or designee will coordinate with the vendor to schedule annual load test and ensure necessary documentation is depicted.
Facility generator logs and vendor documentation will be reviewed by NHA or designee ensuring monthly testing was completed, and annual load tests occur x1 year. Findings will be reviewed at QAPI for further evaluation and recommendations.

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