Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Utz Terrace during CMS and state inspections, most recent first.
Food Storage and Sanitation Deficiencies: Surveyors observed multiple food safety and sanitation issues, including unlabeled or improperly dated food items in the kitchen, expired sanitation test strips, an open flour bin with the scoop stored inside, and dirty refrigerators in the dining room and nourishment area. In the service kitchen, plates were stored under an air conditioning unit blowing toward food, and during tray line service a dietary aide touched plate eating surfaces and food with gloved hands. The dietary manager and NHA acknowledged the unsanitary conditions.
A resident with pseudomonas aeruginosa and COPD was on contact precautions, but an employee entered the room to give meds without wearing the required gown and gloves, and the care plan did not address the precautions. The facility also lacked documented water management checks, including chlorine, water temperature, and pressure monitoring, because the tasks were not assigned to staff.
A resident with CKD and bladder neck obstruction, who required a suprapubic catheter, was observed ambulating in the hallway with the catheter bag and tubing exposed and visible urine in both. Facility policy stated catheter tubing and drainage bags should be kept off the floor and in a dignity bag, and the NHA acknowledged the bag should have been covered.
Unsafe Stove Access in Activity Room: A stove in the activity room was observed with burners that could be turned on and heat up while the Activity Director was in her office nearby with the door and blinds closed. The main power was controlled by a key lock box in the office, and the key was found in the on position. No residents were present in the area during the observation, and the NHA confirmed the last cooking activity had occurred earlier in the month.
Surveyors found that the facility did not review and revise care plans for two residents: one receiving anticoagulant therapy for atrial fibrillation and another with ongoing stage 3 pressure ulcers. The care plans lacked focus areas for anticoagulant medication and pressure wound management, despite clinical records and wound evaluations indicating the need for these interventions. The DON acknowledged the omissions during interviews.
Residents reported not receiving menu items due to food running out, and staff substituted items on meal tickets when the posted menu could not be followed. A resident and her family expressed concerns about not receiving selected menu items and the quality of food, while staff confirmed that production sheets were not used and menu selections were made at the time of service.
Two residents reported that food was often unpalatable and served at improper temperatures, with one family member also noting menu substitutions and inedible meals. A test tray audit confirmed that some food items were bland, overcooked, and did not meet required temperature standards, with staff acknowledging delays in tray delivery and temperature issues.
The facility did not follow required procedures for labeling and dating food items in the kitchen freezer and failed to consistently record food temperatures for multiple dinner meals, as confirmed by staff and documentation review.
A resident with hemiparesis and a history of stroke was found with significant facial hair, indicating a failure by the facility to assist with personal hygiene. The resident expressed feeling depressed about the facial hair and was willing to accept staff assistance. The facility's care plan lacked documentation of any refusal of care, and the resident was last shaved by staff weeks prior.
The facility failed to maintain oxygen equipment for two residents, both requiring supplemental oxygen. One resident with diabetes and respiratory failure, and another with atrial fibrillation and congestive heart failure, had humidification bottles that were not changed weekly as ordered. The DON confirmed the oversight.
Food Storage and Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the facility kitchen areas. During a tour of the main kitchen, surveyors observed an open bag of vanilla yogurt in the walk-in refrigerator with no opened date, a metal tray of biscuits dated May 23, 2026 with tears in the foil covering, and an unlabeled bag of soup in the walk-in freezer with a tear in the plastic. On a spice rack, multiple opened seasonings and sauces were found with dates ranging from July 25, 2025 to March 14, 2023, including one bottle of browning and seasoning sauce with a manufacturer best-by date of July 14, 2024. The cook stated that spices were dated when received and thought they were to be discarded after six months, but needed to verify that with the dietary manager. Surveyors also observed food handling and sanitation concerns in the kitchen. The lid on the flour bin was slid open and the scoop was stored inside the flour; the cook reached in with bare hands to remove the scoop. The test strips for the three-compartment sanitation sink had expired on December 1, 2025. In a food prep area, an opened bottle of vanilla flavoring was dated May 30, 2025. In the service kitchen, an uncovered serving rack of plates was stored upright directly under a window with an air conditioning unit running, and the dietary aide stated the unit was turned off during food service because it blew directly onto the food. Additional sanitation issues were found in the dining room refrigerator and nourishment area. The refrigerator by the beverage dispenser had a black splatter in the back and a black spill in the bottom, and a dietary aide said staff wiped it down when they had time. In the nourishment area near the nursing desk, individual packets of jellies, salad dressings, and hot chocolate had no dates noted, and the refrigerator had small brown spills on a shelf and in the bottom. During tray line observation, a dietary aide used gloved hands to pick up tray tickets, then touched the eating surface of plates twice, pushed spaghetti noodles back onto a plate twice, and picked up a garlic roll once. The dietary manager and nursing home administrator acknowledged the observations and confirmed that sanitary conditions were not followed.
Failure to Follow Contact Precautions and Water Management Monitoring
Penalty
Summary
Staff failed to implement transmission-based precautions for Resident 43, who had diagnoses including pseudomonas aeruginosa and COPD. The facility policy for contact precautions required staff to don PPE upon room entry and discard it before exiting the room. On May 27, 2026, Resident 43 was observed sitting in his room with a contact precautions sign posted outside the room indicating that gloves and a gown were required before entry and removed before exit. During that observation, Employee 3 entered the room to administer medications without putting on any of the required PPE. Review of Resident 43's care plan did not reveal a care plan addressing the resident's need for contact precautions. The facility also failed to complete required water management control measures from July 1, 2025, through January 19, 2026. The water management policy required daily free chlorine checks at the boiler room point of entry, daily hot and cold water temperature checks, daily water system pressure checks, and weekly hot and cold water temperature checks in four randomly chosen resident rooms. Employee 13, the Director of Buildings and Grounds, stated the facility could not provide documented control measures for that period and said the checks were not performed because of newly hired employees and a failure to assign the task to staff. The NHA acknowledged that the waterborne pathogen control measures should have been assigned and completed based on the facility water management plan.
Exposed catheter bag and tubing during ambulation
Penalty
Summary
The facility failed to ensure a resident’s right to a dignified existence and to be treated in a manner and environment that enhances quality of life when Resident 4 was observed ambulating in the hallway with a suprapubic catheter bag and tubing exposed. The resident had diagnoses including chronic kidney disease and bladder neck obstruction, and the interdisciplinary plan of care identified the need for a suprapubic catheter. During the observation, both the catheter bag and tubing were visible and contained urine. The facility policy titled Catheter Care, Urinary stated that catheter tubing and drainage bags should be kept off the floor and in a dignity bag, and the Nursing Home Administrator acknowledged that the resident’s catheter bag should have been covered with a dignity bag.
Unsafe Stove Access in Activity Room
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards in the activity room. During an observation of the Activity Room, a stove was present, and when a surveyor turned one of the burners to the on position, the burner began heating. The Activity Director was in her office in the corner of the same Activity Room with the door and window blinds closed and was notified immediately of the observation. She accompanied the surveyor to the stove and acknowledged that the stove burners and oven could be turned on. She also stated that the main power to the stove was controlled by a key lock box located in her office, and the key in the lock box was turned to the on position. The Activity Director then turned the key to the off position, and the stove could no longer be turned on. When asked when the stove had last been used, she said she would need to investigate and follow up. No residents were in the area at the time of the observation. The facility’s May activity calendar showed a cooking activity, and the Nursing Home Administrator confirmed that the last cooking activity occurred on that date. He also stated that he had removed the key from the lock box in the Activity Director’s office and was in the process of writing a policy to address the safe use of the stove.
Failure to Review and Revise Care Plans for Anticoagulant Use and Pressure Ulcers
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for two residents as required. For one resident with diagnoses including atrial fibrillation and cardiomyopathy, the clinical record showed a physician's order for Xarelto, an anticoagulant, but the care plan did not include a focus area related to anticoagulant medication. The Director of Nursing stated that they believed an adequate care plan had been enacted, but review of the documentation did not support this. For another resident with stage 3 pressure ulcers on the sacrum and back, wound evaluations documented the ongoing presence of these wounds over several weeks. Despite this, the resident's care plan did not include a focus area related to pressure wounds or skin care. The Director of Nursing indicated that the care plan for ongoing skin care had been inadvertently removed. These findings were based on clinical record reviews, wound evaluations, observations, and staff interviews.
Failure to Provide Sufficient Food as Posted on Menu
Penalty
Summary
The facility failed to provide sufficient food to meet resident requests as outlined on the posted menu for at least one observed meal. Meeting minutes from the food service committee indicated that residents reported food items running out and not receiving the menu items as posted. One resident stated she did not always receive her selected menu items because the facility ran out of food, and her daughter also submitted a grievance noting that her mother did not receive selected menu items and that the food provided was often inedible. During observation, the posted lunch menu included citrus roasted pork, baked sweet potato, broccoli, and butterscotch pudding, with a vegetable Alfredo as an alternate entrée. However, it was observed that staff altered several residents' meal tickets due to running out of sweet potatoes, substituting mashed potatoes instead. Staff interviews revealed that production sheets were not used and that residents made their menu selections at the time of service, rather than in advance. The Nursing Home Administrator confirmed that sufficient food should be prepared to serve the posted menu.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at appetizing temperatures during one observed meal. Interviews with two residents revealed dissatisfaction with the taste and temperature of the food, with both stating that hot food was often served cold. Additionally, a grievance submitted by a resident's daughter indicated that her mother did not receive selected menu items due to the facility running out of food, and that the food provided was frequently inedible. A review of the facility's Tray Line Test Tray Audit showed that the standard for hot entrees and vegetables is a temperature of at least 135 degrees Fahrenheit, and that food should be evaluated for flavor and texture. During a test tray evaluation, it was found that the vegetable dish was bland and overcooked, and the temperature of some items did not meet the facility's standards. The tray had been left on a meal cart for 18 minutes before evaluation, contributing to the temperature issues. Staff interviews confirmed that the food temperatures were not to company standards and acknowledged delays in tray assembly.
Failure to Properly Label, Date, and Monitor Food Temperatures
Penalty
Summary
The facility failed to store and serve food and beverages in accordance with professional standards for food safety, as evidenced by observations and staff interviews. In the main kitchen's walk-in freezer, three packages of naan bread were found outside of their cardboard case and were not date marked, contrary to the facility's policy requiring all food items to be labeled with a manufacturer or handwritten label and dated upon receipt. Additionally, a review of the food temperature logs in the kitchenette revealed that food temperatures were not recorded for eight dinner meals over the past 27 days, despite facility policy mandating that food temperatures be recorded for all hot and cold foods prior to meal service. Staff interviews confirmed that these procedures were not followed as required.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident 12, who has medical diagnoses including hemiparesis and a cerebral vascular accident, was observed with significant facial hair, particularly on the upper lip and chin. The resident expressed feeling depressed about the facial hair and indicated a willingness to accept staff assistance for its removal. The interdisciplinary plan of care for Resident 12 noted impaired function with activities of daily living but lacked documentation regarding any refusal of personal hygiene care, including shaving. The Director of Nursing confirmed that the resident was last shaved by staff on April 28, 2024, and acknowledged the condition promoting excessive hair growth. Despite this, there was no additional information provided by the facility regarding the prominent facial hair observed during the interview on May 14, 2024.
Failure to Maintain Oxygen Equipment for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as evidenced by the improper maintenance of oxygen equipment. Resident 10, who has diagnoses including diabetes mellitus and respiratory failure, was observed with an oxygen concentrator humidification bottle that had not been changed since May 3, 2024, despite physician orders requiring weekly changes. The Medication Administration Record indicated that the equipment should have been changed on May 9, 2024, but this was not done. Similarly, Resident 28, diagnosed with atrial fibrillation and congestive heart failure, was also observed with an oxygen concentrator humidification bottle that had not been changed since May 3, 2024. Physician orders for Resident 28 also required weekly changes of the oxygen equipment, which were not followed as the Medication Administration Record showed the change was due on May 9, 2024. The Director of Nursing confirmed that both residents required supplemental oxygen and that the humidification bottles should have been changed weekly as per the physician's orders.
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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 Hanover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Homewood Living Plum Creek, Inc | 3.9 mi | ★★★★★ | 1 | 0 |
| Hanover Hall For Nursing And Rehabilitation | 4.3 mi | ★★★★★ | 14 | 0 |
| Autumn Lake Healthcare At Long View | 6.3 mi | ★★★★★ | 13 | 0 |
| Cross Keys Village-brethren Home Community, The | 12.2 mi | ★★★★★ | 0 | 0 |
| Atlee Hill Health And Rehab Center | 13.3 mi | ★★★★★ | 41 | 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.