Concordia at Spiritrust Gettysburg: Meal Portioning Failure - PA
The meal that day was baked manicotti with tomato sauce. The facility's own menu extension sheets required two pieces per resident, totaling six ounces. At 11:45 AM, as trays moved down the line, five residents — identified in inspection records as Residents 6, 21, 28, 29, and 35 — received one manicotti each. Their tray tickets said two.
At 11:56 AM, Employee 2, a dietary worker, paused the tray line to prepare flounder for the alternate menu and asked how service was going. The surveyor told him. Employee 2 said the manicotti were pretty big, so he had given one, estimating they weighed at least three ounces each.
The facility's own recipe set a single portion at six ounces. Not three.
The Director of Dining Services, Employee 1, weighed one manicotti from the steam table pan at 11:59 AM. It came in at approximately five ounces. He agreed it was the wrong portion size.
The Nursing Home Administrator, interviewed at 12:17 PM the same day, said she would expect recipes to be followed and appropriate portions to be served.
Inspectors noted the facility's recipe policy, last reviewed March 23, 2026, required recipes to be "followed exactly." The production sheet policy, also reviewed that month, required staff to adhere to portion sizes listed for each meal.
CMS rated the violation as minimal harm or potential for actual harm, with few residents affected. The deficiency was cited under Pennsylvania Code governing licensee responsibility.
For residents in long-term care, consistent nutrition is not incidental. Portion control policies exist precisely because dietary staff making judgment calls in the moment — deciding something looks big enough — is how residents end up short.
Five of them were, that Wednesday, before anyone with authority to notice happened to be standing there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Concordia At Spiritrust Gettysburg from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
CONCORDIA AT SPIRITRUST GETTYSBURG in GETTYSBURG, PA was cited for violations during a health inspection on April 30, 2026.
The meal that day was baked manicotti with tomato sauce.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.