Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 United Zion Retirement Communi during CMS and state inspections, most recent first.
Staff failed to monitor and control the temperature of hot liquids served to a resident, contrary to facility policy limiting hot beverage temperatures and microwave heating volumes. After hours, when dietary staff were unavailable and beverages prepared by non-dietary staff were not temperature-checked, a CNA heated approximately 8–10 oz of water in a ceramic mug in the microwave, added honey and tea, and served it without checking the temperature. The resident, who had CHF, muscle wasting/atrophy, intact cognition, and required set-up assistance for meals, attempted to reposition a recliner closer to the bedside table, upended the table, and spilled the hot tea onto the chest and thigh, causing burns later documented as including a full-thickness wound. A reenactment showed that heating 8 oz of water for two minutes in the same type of mug produced a temperature above the facility’s stated maximum serving temperature.
A facility failed to ensure a physician's discharge summary was completed for a resident prior to or at the time of discharge. The resident was discharged without the necessary documentation, as confirmed by the Nursing Home Administrator.
A facility failed to document non-pharmacological interventions before administering PRN anti-anxiety medication to a resident. The resident was given Lorazepam multiple times without appropriate indication or attempts at non-pharmacological interventions, as confirmed by the Nursing Home Administrator.
Failure to Monitor Hot Beverage Temperatures Resulting in Resident Burns
Penalty
Summary
The facility failed to ensure staff monitored and controlled the temperature of hot liquids served to residents, resulting in burn injuries to one resident. Facility policy on Safety of Hot Liquids required hot liquid serving temperatures to be maintained at no more than 180°F, and a procedure directed that liquids heated in the microwave be limited to 6 ounces per one beverage cycle. Despite this, a CNA prepared approximately 8–10 ounces of water in a ceramic mug from the ice and water machine, heated it in the microwave for two minutes, then added four packets of honey and a tea bag before serving it to a resident. The temperature of the beverage was not checked. The incident occurred after kitchen hours when no dietary staff were present, and the DON reported that food and beverages prepared by non-dietary staff after hours were not temperature-checked. A subsequent reenactment using 8 ounces of cold water heated for two minutes in the same type of mug showed a temperature of 187.6°F, exceeding the facility’s stated maximum serving temperature. The resident involved, who had diagnoses including congestive heart failure and muscle wasting/atrophy, had a BIMS score of 15 indicating intact cognition and was documented as independent with eating, though an occupational therapy note indicated a need for set-up and clean-up assistance for meals. On the evening of the incident, the resident requested pretzels, hot tea, and honey. After the CNA placed the hot tea and pretzels on the bedside table, the resident used the recliner remote to raise the chair to move closer to the table, caught the bottom of the bedside table, and upended it, spilling the hot tea onto the right chest and right hip area. A nursing progress note documented slightly red skin with a thin layer of skin peeling off immediately after the spill. A wound specialist’s evaluation five days later identified two burn wounds: a full-thickness wound on the right posterior thigh measuring 13.7 cm x 5 cm with unmeasurable depth due to tissue overgrowth, and a wound on the right chest measuring 4 cm x 5.6 cm with unmeasurable depth due to tissue overgrowth. The DON’s investigative report confirmed the resident was provided hot tea of unknown temperature, and both the DON and NHA acknowledged the resident received a hot beverage of unknown temperature resulting in multiple burn injuries.
Failure to Complete Physician's Discharge Summary
Penalty
Summary
The facility failed to ensure that a physician's discharge summary was completed prior to or at the time of discharge for a resident. The clinical record review revealed that the resident was discharged on May 6, 2024, but there was no evidence of a completed discharge summary by the physician at the time of discharge. This deficiency was confirmed during an interview with the Nursing Home Administrator on July 18, 2024.
Failure to Document Non-Pharmacological Interventions Before Administering PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented before administering as-needed anti-anxiety medication to Resident 14. According to the clinical records review and staff interview, Resident 14 had a physician's order for Lorazepam, an anti-anxiety medication, to be taken as needed for anxiety. However, from June 15, 2024, to June 26, 2024, the medication was administered seven times without appropriate indication for use and ten times without attempts to provide a non-pharmacological intervention prior to administration. An interview with the Nursing Home Administrator confirmed the lack of documentation for non-pharmacological interventions and appropriate indications for the medication. This deficiency was identified under 28 Pa. Code: 211.12(d)(5) and 28 Pa. Code: 211.12 (d)(1)(3) related to nursing services.
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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 Lititz
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kadima Rehabilitation & Nursing At Lititz | 4.4 mi | ★★★★★ | 4 | 0 |
| Moravian Manor | 4.5 mi | ★★★★★ | 5 | 0 |
| Pleasant View Communities | 4.5 mi | ★★★★★ | 0 | 0 |
| Luther Acres Manor | 4.6 mi | ★★★★★ | 2 | 0 |
| Cornwall Manor | 6.6 mi | ★★★★★ | 0 | 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.