Spiritrust Lutheran The Village At Utz Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Hanover, Pennsylvania.
- Location
- 2100 Utz Terrace, Hanover, Pennsylvania 17331
- CMS Provider Number
- 396111
- Inspections on file
- 16
- Latest survey
- April 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Spiritrust Lutheran The Village At Utz Terrace during CMS and state inspections, most recent first.
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.
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.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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