Concordia At Spiritrust Gettysburg
CONCORDIA AT SPIRITRUST GETTYSBURG in GETTYSBURG, PA — inspection on April 30, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 39's clinical record revealed diagnoses that included presence of right artificial knee joint, encounter for orthopedic aftercare, and muscle weakness.
Review of Resident 39's clinical record failed to reveal a physician order or a care plan for her code status (a medical designation that indicates what life saving treatments a patient would or would not want if their heart or breathing stops).
Review of Resident 39's hard paper medical chart on [DATE], at 12:56 PM, failed to reveal a POLST form (Physician Orders for Life Sustaining Treatment- a medical order that allows seriously ill or frail individuals to specify the types of medical treatment they want during emergencies).
During an interview with Employee 3 (Registered Nurse) on [DATE], at 12:58 PM, the surveyor asked if Employee 3 could find Resident 39's code status in her electronic or paper medical record.
Employee 3 stated it is usually in the physicians orders and under additional instructions in the electronic chart, and she was unsure of why she didn't have a POLST in her paper chart for reference.
Employee 3 couldn't find it after one minute and stated she would not wait any longer to search at that point, and if Resident 39 started to code (a life threatening medical emergency requiring immediate resuscitation efforts), she would treat her as a full code and start performing CPR (Cardiopulmonary Resuscitation, an emergency procedure used to maintain blood flow and oxygen to vital organs when the heart stops beating).
During an interview with Employee 8 (Licensed Practical Nurse) on [DATE], at 1:03 PM, she revealed if she could not find a resident's code status in their electronic or paper medical record, she would start CPR and treat them as a full code.
During an interview with Resident 39 on [DATE], at 1:06 PM, she revealed Employee 9 went over advance directive information with her when she was admitted to the facility, and that her wishes are for DNR (Do Not Resuscitate- a medical order indicating that a person does not want CPR or other life-saving measures if their heart or breathing stops).
Review of Resident 39's clinical record revealed a note written by Employee 9 (Social Worker) on [DATE], that stated POLST form reviewed, continues to decline to complete POLST but does request DNR code status.
Interview with the Director of Nursing on [DATE], at 11:11 AM, she revealed Resident 39's DNR code status order was missed from the batch physician orders and failed to be transcribed to the electronic chart orders.
She stated that she would expect the order would have been put in electronically to be easily found by nursing staff in the event of a life threatening emergency. 28 Pa.
Code 201.29 (a) Resident Rights28 Pa.
Code 211.12 (d)(1)(3)(5) Nursing services28 Pa.
Code 211.5 (f)(i) Medical Records Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
395647 04/30/2026
Concordia at Spiritrust Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325
Review of Resident 39's clinical record revealed diagnoses that included presence of right artificial knee joint and muscle weakness.
Review of Resident 39's physician orders revealed an order for Ampicillin Sodium Intravenous (IV) Solution Reconstituted 2 gram, use 2000 milligram intravenously every 6 hours for cellulitis (infection), with a start date of April 15, 2026.
Review of Resident 39's MAR (Medication Administration Record - record of medications and treatments administered) revealed she is to get the Ampicillin IV medication at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM, daily.
Review of Resident 39's care plan revealed a care plan focus area, I am at risk of complications as I have IV therapy for infection, with an intervention for IV therapy as ordered, initiated on April 14, 2026.
Observation and resident interview in Resident 39's room on April 28, 2026, at 12:28 PM, revealed she had not yet received her IV medication to be administered at 12:00 PM and she was not sure why.
Additional surveyor observation on April 28, 2026, at 1:13 PM, revealed the IV antibiotic had yet to be administered for the noon dose.
During an interview with the Director of Nursing (DON) on April 29, 2026, at 1:45 PM, the surveyor revealed the concern with the late IV administration on April 28, 2026.
Review of Resident 39's clinical record revealed a nursing progress note from April 29, 2026, at 2:58 PM, that read, IV Ampicillin due 1200 on 4/28/26 given pass admin time and marked late on MAR.
Med given at 1320 and marked on MAR at
- No signs or symptoms of infection noted.
Incision to right knee well approximated, no drainage or redness noted. [Physician] aware with no new orders.
Husband and resident both aware and voice no concerns over time that dose was given.
Review of Resident 39's April MAR report revealed Resident 39's ampicillin dose was marked as given late on two other occasions.
For the 12:00 AM dose on April 27, 2026, it was noted to be documented as administered at 2:20 AM; for the 12:00 AM dose on April 30, 2026, it was noted to be documented as administered at 1:56 AM.
Interview with the DON on April 30, 3036, at 12:31 PM, revealed nurses can start the administration of a medication but get tasked with other priorities such as ADL care/toileting for the resident or an emergent situation that would require attention, and sign as completed at a later time. If those situations occur, a progress note should be put into the record as to why the medication was administered late or signed late but given on time.
She further revealed her expectation that medications are administered timely and as ordered. 28 Pa.
Code 201.18(b)(1) Management28 Pa.
Code 211.12 (d)(1)(3)(5) Nursing services
395647 04/30/2026
Concordia at Spiritrust Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325
Observation of wound care on Resident 7 on April 30, 2026, at 9:45 AM, revealed Employee 6 (Licensed Practical Nurse) using her clean gloved hand to remove a pen marker from under her PPE gown, then lifted the cuff of her scrub jacket to check the time, labeled the border foam dressing, then used the same gloved hand to pick up the calcium alginate silver and place it into the wound bed.
During an interview with the Nursing Home Administrator (NHA) on April 30, 2026, at 11:31 AM, the NHA agreed that policy should be followed for dressing changes. 28 Pa.
Code 211.12(d)(1)(2)(5) Nursing services.
395647 04/30/2026
Concordia at Spiritrust Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325
Review of Resident 5's clinical record revealed diagnoses that included Asthma (a chronic, non-curable lung disease causing airway inflammation and muscle tightening) and obstructive sleep apnea (serious, common sleep disorder where throat muscles relax excessively, causing repeated airway collapse and breathing pauses [apnea] during sleep).
Observation of Resident 5 on April 27, 2026, at 10:56 AM, revealed Resident 5 lying in bed. Resident 5 was wearing a nasal canula (oxygen delivery device) and receiving supplemental oxygen at 3 liters per minute and the oxygen tubing was not dated.
Observation of Resident 5 on April 29, 2026, at 11:46 AM, revealed Resident 5 lying in bed. Resident 5 was wearing a nasal canula (oxygen delivery device) and receiving supplemental oxygen at 3 liters per minute and the oxygen tubing was not dated.
Review of Resident 5's care plan revealed a care plan of: I have potential complications as I have asthma and restrictive lung disease, and an intervention of: give oxygen therapy as ordered, with a date initiated on June 17, 2016.
Review of current physician orders for Resident 5 revealed an order for oxygen via nasal canula at 2-4 liters per minute, starting December 4, 2025.
Interview with the Director of Nursing (DON) on April 29, 2026, at 1:15 PM, revealed that Resident 5's oxygen tubing should have been dated when it was applied or changed.
Further interview revealed that the facility did not have a policy regarding supplemental oxygen use.
Review of Resident 37's clinical record revealed diagnoses that included heart failure (a chronic, progressive condition where the heart cannot pump blood efficiently, leading to fatigue, shortness of breath, and fluid buildup) and muscle weakness (weakness in the muscles not explained by any medical diagnosis).
Observation of Resident 37 on April 27, 2026, at 12:56 PM, revealed Resident 37 sitting in her recliner. On the table beside her, her nebulizer mask was sitting out on the table not covered or in a bag.
Observation of Resident 37 on April 29, 2026, at 10:46 AM, revealed Resident 37 sitting in her recliner. On the table beside her, her nebulizer mask was sitting out on the table not covered or in a bag.
Review of Resident 37's care plan revealed a care plan with the focus area of, I have difficulty breathing due to CHF (congestive heart failure), with a revision date of January 11, 2025.
Review of Resident 37's physician orders revealed an order for albuterol sulfate solution given via nebulizer daily at bedtime, with a start date of March 23, 2026.
Interview with the DON on April 29, 2026, at 2:15 PM, revealed that she would expect the resident's mask to be cleaned and put away after use.
Further interview revealed that the facility did not have a policy regarding nebulizer use. 28 Pa.
Code 211.12(d)(1) Nursing services28 Pa.
Code 211.12(d)(3) Nursing services28 Pa.
Code 211.12(d)(5) Nursing services
395647 04/30/2026
Concordia at Spiritrust Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325
Review of facility policy, titled Production Sheet last reviewed March 23, 2026, read, in part, A production sheet is developed for each meal based on the menu cycle. To ensure that the production team prepares menu items in the correct quantity and adheres to company standards of food quality.
There is a production sheet for each meal.
Included on this sheet are: All items to be prepared for that meal, their recipe number, and portion size.
Quantity to be produced based on resident diet census form for all items listed.
Review of facility menu extension sheets revealed the main meal served on Wednesday April 29, 2026, was to consist of two Baked Manicotti with tomato sauce (6 ounces- unit of measure), 4-ounces of Vegetable Blend, a 2-ounce Warm Dinner Roll with Butter, and one slice of Pound Cake with Fruit Topping.
Observation during tray line meal service on April 29, 2026, 11:45 AM, revealed Residents 6, 21, 28, 29, and 35 were served only one manicotti.
Observation of their meal tray tickets revealed they should have been served two. On April 29, 2026, at 11:56 AM, Employee 2 (Dietary Employee) paused the tray line meal service to make more fish flounder for the alternate menu and asked how the meal service was going.
The surveyor revealed the concern with only one manicotti being served instead of two.
Employee 2 then stated the manicotti were pretty big so he only gave one as they were at least three ounces.
Review of facility recipe for the manicotti on April 29, 2026, at 11:59 AM, revealed one portion size of the manicotti was 6 ounces.
During an interview with Employee 1 (Director of Dining Services) on April 29, 2026, at 12:17 PM, revealed he weighed one manicotti from the pan on the steam table and it weighed approximately 5 ounces, but he was in agreement that it was the incorrect portion size.
Interview with the Nursing Home Administrator on April 29, 2026, at 12:17 PM, she revealed she would expect recipes to be followed and appropriate portions to be served during meal service. 28 Pa.
Code 201.14(a) Responsibility of licensee
395647 04/30/2026
Concordia at Spiritrust Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325
During an interview with Employee 3 (Licensed Practical Nurse), the Employee was asked to review her process during use of the glucometer on a resident.
Employee 3 demonstrated cleaning the glucometer after use with alcohol wipes and placing it on the medication cart to air dry prior to storing it back in the medication cart.
The Employee pulled a container of bleach wipes (EPA recommended disinfectant) from the medication cart and stated, I probably should use these, but I'm old school and prefer alcohol wipes.
During an interview with Employee 4 (Licensed Practical Nurse), the Employee was asked to review her process during use of the glucometer on a resident.
Employee 4 stated the following, After use, I wipe the glucometer down with alcohol wipes, and lay it down to air dry, then store it in the medication cart.
During an interview with the Nursing Home Administrator (NHA) on April 30, 2026, at 11:30 AM, the NHA was asked if she expected staff to disinfect the glucometer per manufacturer's recommendations.
The NHA replied, I expect staff to follow the policy. 28 Pa.
Code 211.12(d)(1)(2)(5) Nursing services
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.