Concordia at Spiritrust Utz Terrace: Infection Failures - PA
The resident, identified in inspection records only as Resident 43, had been diagnosed with pseudomonas aeruginosa, a bacterium that causes serious, sometimes fatal infections, particularly in people with compromised immune systems or underlying lung disease. Resident 43 also had chronic obstructive pulmonary disease. He was sitting in his room when the employee, identified as Employee 3, walked in and administered his medications without any protective equipment at all.
The sign was there. The policy was there. The employee walked past both.
Inspectors from the Pennsylvania Department of Health visited Concordia at Spiritrust Utz Terrace, a nursing home at 2100 Utz Terrace in Hanover, on May 27 and 28, 2026. What they documented goes beyond a single nurse skipping a gown. The inspection report describes a facility that also went more than six months without completing any of the water safety checks it had committed to performing to prevent the growth of Legionella, the bacterium responsible for Legionnaires' disease, a severe and potentially fatal form of pneumonia.
Nobody had been assigned to do the checks. Nobody noticed they weren't being done.
The facility's own Water Management Policy, last reviewed as recently as April 1, 2026, laid out a specific set of control measures. Staff were supposed to test free chlorine levels at the boiler room's point of entry every single day. They were supposed to check hot and cold water temperatures at the boiler room daily. They were supposed to monitor water system pressure daily. Every week, four randomly chosen resident rooms were to have their hot and cold water temperatures tested, a precaution designed to catch conditions where Legionella could grow and spread through the building's plumbing.
The policy even specified what should happen if any of those readings fell outside acceptable limits: the supervisor or Director of Buildings and Grounds was to be notified immediately.
None of it happened. Not for a single day between July 1, 2025, and January 19, 2026.
The Director of Buildings and Grounds, identified in inspection records as Employee 13, told inspectors the facility could not produce any documented control measures from that entire period. The reason, Employee 13 said, was that the facility had recently hired new employees and had simply failed to assign the water monitoring tasks to anyone. For more than six months, a building full of elderly residents, many of them with the kinds of underlying health conditions that make Legionnaires' disease especially dangerous, had water flowing through its pipes with no one checking whether conditions were safe.
The Nursing Home Administrator agreed, during an interview with inspectors on the morning of May 28, 2026, that the waterborne pathogen control measures should have been assigned and completed. That much was not in dispute.
Legionella thrives in water systems where temperatures fall into a certain range and where water sits stagnant, conditions that can develop in any large building but that are especially concerning in healthcare settings. The facility's own policy identified the key risk factors: water temperatures outside the safe range, stagnation in unoccupied rooms, inadequate disinfection, and sediment or biofilm buildup in pipes. Checking chlorine levels and water temperatures regularly is how facilities catch those problems before they become crises. Concordia at Spiritrust Utz Terrace stopped checking entirely, for reasons that amounted to a paperwork and staffing oversight that lasted half a year.
The PPE failure with Resident 43 is its own problem, distinct from the water monitoring lapse but connected by the same thread: infection control measures that existed on paper and failed in practice.
Pseudomonas aeruginosa is not a minor pathogen. It is resistant to many antibiotics and is a leading cause of hospital-acquired infections. In people with lung disease, it can colonize the airways and prove extremely difficult to eradicate. Contact precautions, the protocol Resident 43 was placed on, exist specifically because pseudomonas can spread through environmental contamination, meaning surfaces, hands, clothing. The gown and gloves that Employee 3 skipped are not bureaucratic formalities. They are the mechanism by which the bacterium is kept from traveling out of one room and into the next.
The facility's own Transmission-Based Precautions policy, revised in April 2024, stated clearly that donning personal protective equipment upon room entry and discarding it before exiting is done to contain pathogens, especially those that spread through environmental contamination. Pseudomonas aeruginosa is precisely that kind of pathogen.
There was a sign on the wall. The sign said gloves and gown, required.
When inspectors reviewed Resident 43's care plan, they found something else missing: there was no care plan entry addressing his need for contact precautions at all. The sign was posted. The policy existed. But the formal, individualized care planning that should have reinforced and tracked the precautions for this specific resident had not been completed.
The Nursing Home Administrator, interviewed on the afternoon of May 28, said the expectation was that staff would use correct PPE when entering rooms that required it. That expectation and the observation inspectors recorded the previous morning were not reconcilable.
Concordia at Spiritrust Utz Terrace is operated under the Spiritrust Lutheran system, a nonprofit organization. The inspection was completed May 28, 2026, and the deficiencies were cited under Pennsylvania Department of Health regulations governing nursing services, licensee responsibility, and management.
The level of harm for both deficiencies was cited at the lower end of the federal scale, characterized as minimal harm or potential for actual harm. That designation reflects the regulatory framework's assessment at the time of inspection. It does not account for what might have been growing in the pipes during the months when no one was testing, or for what might have left Resident 43's room on the hands and clothing of a nurse who walked in without protection and walked back out the same way.
Resident 43 was sitting in his room. He had pseudomonas in his body and a lung disease that had already compromised his breathing. The sign on his wall said what needed to happen before anyone came inside. It said it clearly enough that inspectors, walking past on a routine visit, understood it immediately.
The nurse who gave him his medications that morning did not stop to put on a gown. Did not stop to put on gloves. Walked in, administered the medications, and walked back out into the hallway, where other residents live.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Concordia At Spiritrust Utz Terrace from 2026-05-28 including all violations, facility responses, and corrective action plans.
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: August 11, 2026 · Our methodology
CONCORDIA AT SPIRITRUST UTZ TERRACE in HANOVER, PA was cited for violations during a health inspection on May 28, 2026.
Resident 43 also had chronic obstructive pulmonary disease.
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.