Pennsylvania Department of Health
SPIRITRUST LUTHERAN THE VILLAGE AT SPRENKLE DRIVE
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 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 December 2, 2025, 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 December 2, 2025, 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 Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291 Based on document review and interview, it was determined the facility failed to perform maintenance of battery-powered emergency lighting sources, affecting the entire component. Findings include: 1. Review of documentation on December 2, 2025, between 9:30 AM and 10:45 AM, revealed the facility failed to perform monthly and annual testing of battery powered emergency lighting sources. Interview at the time of the exit conference with the Administrator, Facilities Director and Facilities Supervisor on December 2, 2025, at 1:15 PM, confirmed the facility failed to perform monthly and annual testing on installed back-up emergency lighting testing.

Plan of Correction - To be completed: 12/19/2025

All battery-powered lighting units were tested upon identification during survey. Any units found to be non-functional were repaired and/or replaced.

Director of Facilities will re-educate the maintenance team members of the requirements to test battery powered emergency lighting.

A preventative maintenance program will be implemented to ensure monthly 30-second and annual 90-minute testing of all battery-powered emergency lighting.

Documentation logs of emergency lighting tests will be reviewed monthlyx3 months and then quarterly x1 year. Findings will be discussed at QAPI for further recommendations.

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 allowed gap margins, and to positively latch in the frame, in one of six smoke zones within the component. Findings include: 1. Observation on December 2, 2025, at 12:00 PM, revealed the Mechanical Room door, within the Therapy Room, had a gap, greater than 3/16 of an inch, at the top and latch side of door. Interview at the time of the exit conference with the Administrator, Facilities Director and Facilities Supervisor on December 2, 2025, at 1:15 PM, confirmed the Mechanical Room door exceeded the allowed gap margins. 2. Observation on December 2, 2025, at 12:05 PM, revealed the Sprinkler Room door, within the Therapy Room, had a gap, greater than 3/16 of an inch, at the top and latch side of door. Interview at the time of the exit conference with the Administrator, Facilities Director and Facilities Supervisor on December 2, 2025, at 1:15 PM, confirmed the Sprinkler Room door exceeded the allowed gap margins.

Plan of Correction - To be completed: 01/31/2026

Supplies needed to correct the mechanical room door and the sprinkler room door to be ordered by Facilities Director. Modification of the doors to occur upon receipt of the materials, but no later than after 14 days of receipt. The spec sheet for the device will be placed in the life safety book for future surveys.

Whole house audit of all hazardous area doors throughout the facility to verify compliant gap margins. Any doors found to be out of compliance will be corrected.

All hazardous area doors will be inspected monthly for compliance with gap margins.

Audits of the hazardous areas doors will be reviewed monthly x 3 months to ensure no concerns, then quarterly x 1 year. Findings will be reviewed at QAPI for further evaluation and recommendations.

NFPA 101 STANDARD Cooking Facilities:

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.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to provide documentation of semi-annual testing of the fixed chemical fire suppression system, in one of six smoke zones within the component. Findings include: 1. Review of documentation on December 2, 2025, between 9:30 AM and 10:45 AM, revealed the facility could not provide documentation, verifying the Kitchen's fixed chemical fire suppression system had been tested/maintained, semi-annually. Interview at the time of the exit conference with the Administrator, Facilities Director and Facilities Supervisor on December 2, 2025, at 1:15 PM, confirmed the facility could not provide one full year of semi-annual suppression system documentation.

Plan of Correction - To be completed: 01/31/2026

The facility is unable to duplicate the missing tag from the semi-annual testing of the suppression system.

Facilities Director has confirmed with Clark Fire Services that although testing and maintenance of the fire suppression system are completed, the tags are not retained by their technicians when replaced. Facilities Director notified the company that removed tags are to be provided to the maintenance staff for retention.

The inspection report from the semi-annual testing by Clark Fire Services will be placed in the life safety book for future surveys and will be audited at least semi-annually. In between scheduled semi-annual inspections, maintenance staff will complete and document daily checks of the suppression system for signs of damage or impairment.

Logs will be audited monthly x3 months and then quarterly x 1 year to ensure semi-annual testing/maintenance has occurred. Findings will be presented at QAPI for further evaluation and recommendation.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 perform required weekly and monthly maintenance and testing for the emergency generator, which serves the entire component. Findings include: 1. Review of documentation on December 2, 2025, between 9:30 AM and 10:45 AM, revealed the facility failed to perform the following: a. 9:50 AM, weekly battery voltage readings; b. 9:53 AM, monthly maintenance, 30-minute load w/transfer switch. Interview at the time of the exit conference with the Administrator, Facilities Director and Facilities Supervisor on December 2, 2025, at 1:15 PM, confirmed the facility failed to perform weekly and monthly maintenance and testing on the emergency generator.

Plan of Correction - To be completed: 01/31/2026

Upon identification of the deficiency, the emergency generator system was reviewed with the contracted service provider, Winter's Generator. Winter's Generator confirmed the transfer switch is not able to exercise monthly under load. The system has been adjusted to perform a 30-minute load test with transfer switch every Monday at 8:00 AM. Weekly battery voltage readings were completed and documented.

The Facilities Director will re-educate the maintenance team on proper procedures for checking generator battery voltage readings and accurate documentation of readings.

A generator maintenance log and tracking system will be updated to ensure completion and documentation of weekly battery voltage readings and the scheduled 30-minute load test with transfer switch. Generator service reports from Winter's Generator will be maintained on file.

Logs will be audited monthly x3 months and then quarterly x 1 year. Findings will be presented at QAPI for further evaluation and recommendation.

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