Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Concordia At Spiritrust Luther Ridge during CMS and state inspections, most recent first.
A resident with Parkinson's disease, weakness, and dementia, who was care planned to remain in a reclined BRODA chair to prevent falls, was left in an upright position by a PRN therapy staff member after a treatment session. The resident subsequently fell from the chair, sustaining a facial laceration that required sutures, as staff failed to follow the specified fall prevention intervention.
Surveyors found that several residents did not receive ordered medications due to unavailability, and staff failed to notify practitioners as required by facility policy. Additionally, a resident was observed with a lower extremity splint in use without corresponding physician orders or care plan documentation.
Several residents did not receive prescribed medications, including insulin, Gabapentin, Lorazepam, Torsemide, and levothyroxine, due to unavailability or pharmacy delivery delays. Missed doses occurred for residents with conditions such as diabetes, central pain syndrome, dementia, congestive heart failure, and hypothyroidism, with staff and administration confirming the medications were not administered as ordered.
The facility did not update care plans for two residents after significant changes in their conditions. One resident's care plan was not revised after anticoagulant medications were discontinued following hospitalization, and another resident's care plan lacked a current focus on fall risk despite a recent major fall and high fall risk assessment. Staff confirmed that care plans should have been updated to reflect these changes.
A resident with significant mobility impairments and a history of falls was transferred using a mechanical sit-to-stand lift by a CNA without the required second staff member, in violation of both the care plan and facility policy. During a brief change while in the lift, the resident slid out of the device and fell to the floor. Facility documentation and interviews confirmed that proper supervision and assistance were not provided, leading to the fall.
Two residents continued to receive diclofenac gel orders without specific dosing instructions, despite repeated pharmacist recommendations to clarify the dose. Physicians either did not respond or disagreed with the recommendations, and the orders remained incomplete, contrary to facility policy requiring action on pharmacist-identified medication irregularities.
Surveyors found that two open multi-dose vials of Tuberculin solution in a medication room refrigerator were not dated when opened, contrary to facility policy and staff expectations. Both staff and the NHA confirmed that multi-dose vials should be dated upon opening.
The facility did not have all required QAPI Committee members present at any meeting during a quarter, with absences including the Medical Director, DON, Infection Preventionist, and another staff member, as confirmed by review of sign-in sheets and administrator interview.
The facility did not ensure that all nurse aides completed the required 12 hours of annual in-service training, with two aides receiving only 10 and 6 hours respectively, as confirmed by the administrator.
The facility did not timely report allegations of abuse and neglect involving two residents to the required agencies. One resident with significant mobility issues experienced a fall due to a CNA not following the care plan for mechanical lift transfers, and another resident alleged physical abuse by a staff member. In both cases, the facility failed to notify the local Area Agency on Aging and the state survey agency as required by policy.
The facility failed to ensure timely monthly drug regimen reviews and responses to pharmacist recommendations for several residents. Recommendations for evaluating medication appropriateness and alternatives were not acted upon promptly, as evidenced by delayed or missing responses in residents' records. Interviews confirmed the expectation for timely review and response, which was not met.
A resident was subjected to aggressive behavior by a nurse aide, including being told to stop yelling and being sprayed with water. The incidents were reported days later, violating the facility's policy on timely reporting of abuse.
A resident with CHF and edema had a physician's order for daily weights, with instructions to notify the provider of significant weight gains. However, weights were not recorded on several occasions, and significant weight gains were not reported to the practitioner. The DON could not provide additional information on these lapses.
A facility failed to document comprehensive physician orders for a resident receiving dialysis, including treatment details and provider information, as required by their own care standards. This oversight was confirmed by the DON and involved a resident with end-stage renal disease and atrial fibrillation.
A resident with cellulitis and hypertension did not have complete and accurate documentation of Cefazolin administration in their clinical records. The nurse failed to initial doses on two occasions, and the administration time was incorrectly transcribed. The DON confirmed the need for complete documentation and accurate transcription.
A facility failed to maintain an effective infection control program for a resident with C. diff and pressure ulcers. Observations showed no signage or PPE for contact precautions, and an LPN did not follow proper hand hygiene protocols. The DON confirmed that these measures were expected but not implemented.
Failure to Follow Care Plan for Fall Prevention Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in actual harm to a resident who experienced a fall with a facial injury requiring sutures. The resident had diagnoses including Parkinson's disease, weakness, and dementia, and was identified as being at risk for falls. The resident's care plan specified that she should be seated in a BRODA chair in a reclined position with left lateral support at all times except during meals, to increase comfort and reduce the risk of falls. However, on the day of the incident, the resident was found on the floor in front of her BRODA chair, which was in the upright position, after calling for help. She sustained a 5-centimeter laceration below her right eye, which required 15 sutures at the hospital. Review of staff interviews and facility documentation revealed that a physical therapy assistant, who was a PRN staff member, returned the resident to the television area in her wheelchair in the upright position after a treatment session, failing to follow the care plan intervention requiring the chair to be reclined. Nursing staff confirmed that the resident's wheelchair was not reclined at the time of the fall, and that the reclined position was intended to make it more difficult for the resident to get up unassisted, thereby preventing falls. The failure to follow the care plan intervention directly resulted in the resident's fall and subsequent injury.
Failure to Notify Practitioners of Missed Medications and Lack of Treatment Orders
Penalty
Summary
The facility failed to ensure that practitioners were notified when medications were missed due to unavailability for four residents. For one resident with type II diabetes mellitus and central pain syndrome, Gabapentin was not administered for two consecutive days, totaling six missed doses, without evidence that the practitioner was notified. Another resident receiving hospice care for dementia and anxiety did not receive multiple doses of Lorazepam as ordered, and there was no documentation that the physician was informed of these missed doses. A third resident with congestive heart failure missed a dose of Torsemide, and a fourth resident with congestive heart failure and hypothyroidism missed two doses of levothyroxine, with no evidence of practitioner notification in either case. Additionally, the facility did not provide treatment in accordance with professional standards of practice and physician orders for one resident. This resident, diagnosed with Charcot's joint and gout, was observed wearing a right lower extremity splint. However, there were no physician orders, documentation, or care plan interventions related to the splint at the time of observation. The absence of orders and documentation for the splint was confirmed during interviews and record reviews. These deficiencies were identified through policy review, clinical record review, observations, and interviews with residents and staff. The facility's own policy required staff to notify the pharmacy and the practitioner if a medication was unavailable and a dose would be missed, but this was not followed in the cases reviewed. The lack of documentation and practitioner notification for missed medications and the absence of orders and care planning for the splint constituted failures to provide care and treatment according to orders, resident preferences, and professional standards.
Failure to Provide Timely Pharmaceutical Services Resulting in Missed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of several residents, resulting in multiple missed medication doses. For one resident with type II diabetes and central pain syndrome, Basaglar insulin was not administered due to the insulin pen being unavailable, and Gabapentin was missed over two days because the medication was out of stock and not delivered by the pharmacy in time. Another resident receiving hospice care and diagnosed with dementia did not receive Lorazepam for anxiety over several scheduled doses because the medication was not accessible following a pharmacy change and a delay in staff training on the new medication unit. A resident with congestive heart failure did not receive a scheduled dose of Torsemide as the medication was not available and was awaiting delivery from the pharmacy. Additionally, a resident with congestive heart failure and hypothyroidism missed two doses of levothyroxine because the medication was not available and was still pending arrival from the pharmacy. In each case, the Nursing Home Administrator confirmed that the medications were not administered as ordered due to unavailability or delays in pharmacy delivery.
Failure to Review and Revise Care Plans After Changes in Resident Status
Penalty
Summary
The facility failed to review and revise the care plans for two residents as required by both facility policy and federal regulations. For one resident with a history of long-term anticoagulant use and peripheral vascular disease, the care plan included a focus on potential bleeding and bruising due to aspirin and Plavix use. However, after the resident was hospitalized and both medications were discontinued upon return to the facility, the care plan was not updated to reflect this significant change in medication regimen, despite a comprehensive assessment and care plan review being completed. For another resident with cerebral palsy and spondylosis, a fall with major injury occurred, and a subsequent fall risk evaluation identified the resident as high risk for falls. Despite this, the care plan did not include a current focus on fall risk, and the previous fall care plan had been marked as resolved. Staff interviews confirmed that the care plan should have addressed the resident's ongoing fall risk. These findings demonstrate that the facility did not ensure care plans were consistently reviewed and revised in response to changes in residents' conditions and assessments.
Failure to Follow Transfer Protocols Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with muscle weakness, Charcot's joint of the right ankle/foot, and a chronic non-pressure ulcer of the right heel experienced a fall from a mechanical sit-to-stand lift. The resident's care plan required transfer assistance of two staff members when using the mechanical lift, and facility policy also mandated two team members for such transfers. However, a nurse aide attempted to change the resident's brief while the resident was positioned in the lift, and did so alone, contrary to both the care plan and facility policy. As a result, the resident slid out of the lift's secure device and fell to the floor. Facility documentation, incident reports, and staff interviews confirmed that the nurse aide did not follow the established care plan or facility procedures, which led to the fall. The Nursing Home Administrator acknowledged that the staff member failed to adhere to the required protocols for resident safety and supervision during transfers, resulting in the incident.
Failure to Act on Pharmacist Recommendations for Medication Dosing
Penalty
Summary
The facility failed to ensure that recommendations made by the licensed pharmacist regarding medication orders were reviewed and acted upon by the residents' physicians for two of five residents reviewed for unnecessary medications. Specifically, for two residents with diagnoses including knee pain, muscle weakness, and right shoulder pain, the pharmacist identified that the orders for Voltaren/diclofenac gel were not specific enough, lacking a clearly defined dose as recommended by the manufacturer. The pharmacist made recommendations on two separate occasions for each resident to clarify the dosing instructions, but the physicians either did not respond or disagreed with the recommendation without providing a revised order that included the required dosing information. Clinical record reviews showed that both residents continued to have medication orders for diclofenac gel that did not specify the dose to be administered, despite repeated pharmacist recommendations. The facility's policy required that such recommendations be acted upon and documented, and if the prescriber did not respond, further follow-up was to occur. During an interview, the Nursing Home Administrator confirmed that the physicians should have provided specific dosing orders for the medication, but this was not done.
Failure to Date Opened Multi-Dose Vials in Medication Room
Penalty
Summary
Surveyor observations, review of facility policy, and staff interviews revealed that the facility failed to place opened dates on medications in one of two medication rooms, specifically in the Arlington Unit. During an inspection of the medication storage room refrigerator, two open multi-dose vials of Tuberculin solution were found without open dates. The facility's policy requires that multi-dose vials be dated when opened to ensure infection control and product stability. Both a staff member and the Nursing Home Administrator confirmed that it is the facility's expectation to date multi-dose vials upon opening.
Failure to Ensure Required QAPI Committee Attendance
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assurance Performance Improvement (QAPI) Committee attended at least one meeting during the fourth quarter of 2024. Review of sign-in sheets and documentation showed that the Medical Director was absent from the October meeting, both the Director of Nursing and Medical Director were absent from the November meeting, and the Infection Preventionist along with one additional staff member were absent from the December meeting. The Nursing Home Administrator confirmed that there was no meeting in the quarter where all required members were present, despite the committee meeting monthly.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that each nurse aide received the required minimum of 12 hours of annual in-service training, as evidenced by a review of personnel training records. Specifically, one nurse aide completed only 10 hours and another completed only 6 hours of the mandated training within the past 12 months. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the expectation that nurse aides meet the required training hours. The deficiency was identified through a review of training records for two out of five nurse aide employees, with no additional information provided regarding the medical history or condition of any residents affected by this deficiency.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the required agencies in a timely manner for two residents. For one resident with muscle weakness, Charcot's joint, and a chronic non-pressure ulcer, a fall occurred when a CNA used a mechanical sit-to-stand lift without following the care plan, which required two staff members for transfers. The incident investigation determined that the CNA neglected to follow both the resident's care plan and facility policy. Despite this, there was no documentation that the incident was reported to the local Area Agency on Aging or the state survey agency, as required by facility policy. In a separate incident, another resident filed a grievance alleging that a staff member had kicked him during care. The facility's investigation found the abuse allegation to be unsubstantiated, but again, there was no evidence that the allegation was reported to the required agencies. Interviews with the Nursing Home Administrator confirmed that both incidents should have been reported according to policy, but were not.
Failure to Ensure Timely Drug Regimen Reviews and Responses
Penalty
Summary
The facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, and that irregularities were reported and acted upon in a timely manner. This deficiency was identified for four of five residents reviewed for unnecessary medications. The facility's policy, revised in February 2023, mandates that comments and recommendations concerning medication therapy be communicated in a timely fashion, allowing for a response before the next medication regimen review. However, this policy was not adhered to, as evidenced by the lack of timely responses to pharmacist recommendations. For Resident 2, the pharmacist recommended evaluating the clinical appropriateness and alternative therapy for extended usage of Macrobid on multiple occasions, but the practitioner failed to provide timely responses. The recommendation made in November 2023 was not addressed until March 2024, and a similar recommendation in June 2024 was not responded to at all. Resident 13's records showed recommendations to discontinue PRN Ondansetron and evaluate Hydroxyzine usage, but these were not acted upon in a timely manner. Additionally, a recommendation to consider alternatives due to a high Anticholinergic Burden score was also ignored. Resident 17's medication regimen review for December 2023 could not be located, and a recommendation made in January 2024 was not responded to until March 2024. For Resident 29, a recommendation to adjust Colace dosing was not addressed in a timely manner. Interviews with the Director of Nursing confirmed the expectation that pharmacy recommendations should be reviewed and responded to promptly, which was not the case for these residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse involving a resident, as required by their policy. The incident involved Resident 38, who was subjected to aggressive behavior by Employee 4, a nurse aide. On March 21, 2024, while providing care, Employee 4 aggressively told Resident 38 to stop yelling and used a washcloth to hush her. When the resident continued to scream, Employee 4 placed her fingers in the resident's mouth and nose while mocking her. This incident was reported by Employee 3 to Employee 5, a Registered Nurse Supervisor, on March 24, 2024, three days after it occurred. Additionally, another incident involving Employee 4 was reported by Employee 6, a nurse aide, on the same day. This incident occurred on March 18, 2024, during a bath when Employee 4 sprayed Resident 38 in the face with water out of frustration. Both incidents were reported to the Director of Nursing, who acknowledged that the allegations should have been reported immediately, as per the facility's policy. The delay in reporting these incidents constitutes a failure to adhere to mandatory reporting requirements for suspected abuse.
Failure to Monitor and Report Weight Changes
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with congestive heart failure and localized edema. The resident had a physician's order for daily weights, with instructions to notify the provider if there was a weight gain of more than three pounds in a day or more than five pounds in a week. However, the Treatment Administration Records for June and July 2024 showed that weights were not recorded, nor was there documentation of refusal to be weighed on several dates. Additionally, significant weight gains were recorded on two occasions, but there was no evidence that the practitioner was notified of these changes. The Director of Nursing was unable to provide further information regarding the missed weights or the lack of practitioner notification.
Deficiency in Dialysis Care Documentation
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis treatment was provided care in accordance with professional standards of practice. The deficiency was identified through a review of the facility's policy, clinical records, and interviews with staff and the resident. The facility's policy, titled Hemodialysis Resident Care Standard, mandates the safe medical management of residents receiving dialysis at an external clinic. However, the clinical record of a resident with end-stage renal disease and atrial fibrillation revealed a lack of comprehensive physician orders related to dialysis treatment. The resident, who undergoes dialysis three times a week at an outside facility, did not have physician orders specifying the dialysis treatment, the name of the facility, the frequency of the treatment, or contact information for the dialysis provider. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that such orders should have been documented. The absence of these critical details in the resident's care plan constitutes a failure to adhere to the facility's own policies and professional standards of practice.
Incomplete Medication Documentation for a Resident
Penalty
Summary
The facility failed to document completely and accurately on the clinical records for a resident, identified as Resident 86. The facility's policy, titled Accountability of Medications and Controlled Substances, requires staff to document the administration of all medications given to residents. However, a review of Resident 86's medication administration record revealed that the nurse did not initial the doses of Cefazolin on two occasions, specifically on July 16, 2024, at 7:00 PM, and on July 19, 2024, at 4:00 AM. Additionally, the ordered time for the 7:00 PM dose was incorrectly transcribed and should have been recorded as 8:00 PM based on the every 8-hour administration schedule ordered by the physician. Resident 86, who is cognitively intact with a BIMS score of 15 out of 15, has a physician order for Cefazolin 2 grams intravenously every 8 hours for cellulitis. An observation on July 22, 2024, revealed an empty bag of Cefazolin at the resident's bedside, indicating administration at 8:00 AM as per physician orders. The Director of Nursing confirmed with the pharmacy that three doses are delivered daily, and there were no extra doses on the unit, nor had the resident refused any doses. The DON acknowledged that documentation should be complete and transcription of times should be accurate on resident clinical records.
Inadequate Infection Control for Resident with C. diff
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of appropriate precautions for a resident diagnosed with Clostridium difficile (C. diff) infection and pressure ulcers. The facility's policy required specific precautions, including hand hygiene and the use of personal protective equipment (PPE), for residents with C. diff infections. However, observations revealed that there was no signage indicating contact precautions or Enhanced Barrier Precautions (EBP) in place for the resident, and no PPE was available for use. Additionally, the resident's comprehensive care plan indicated a need for contact precautions, which were not implemented. During a wound care observation, a Licensed Practical Nurse (LPN) failed to perform proper hand hygiene before donning a gown and gloves and after removing soiled dressings. The LPN also used alcohol-based hand rub, contrary to the facility's policy for C. diff infections, which prohibits its use. The Director of Nursing (DON) acknowledged that signage and PPE should have been in place and that proper hand washing was expected during wound care and when caring for residents on contact precautions for C. diff.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chambersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Menno Haven Rehabilitation Center | 3.4 mi | ★★★★★ | 3 | 0 |
| Brookview Health Care Center | 3.5 mi | ★★★★★ | 1 | 0 |
| Laurel Lakes Rehabilitation And Wellness Center | 3.5 mi | ★★★★★ | 7 | 0 |
| Chambers Pointe Health Care Center | 4.2 mi | ★★★★★ | 4 | 0 |
| Transitions Healthcare Shook Home | 4.9 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.