Concordia At Spiritrust Utz Terrace
CONCORDIA AT SPIRITRUST UTZ TERRACE in HANOVER, PA — inspection on May 28, 2026.
Found 4 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 4's physician's orders revealed diagnoses that included chronic kidney disease (gradual loss of kidney function impairing their ability to filter waste) and bladder neck obstruction (a blockage in the neck at the very bottom of the bladder).
Review of Resident 4's interdisciplinary plan of care revealed the need for the use of a suprapubic catheter (a thin, hollow tube made of rubber, silicone, or plastic that allows urine to bypass the urethra and drain directly from the bladder through an incision in the lower abdomen, typically a few inches below the navel). An observation on May 26, 2026, at 10:44 AM, revealed Resident 4 ambulating with his rolling walker, in the hallway with his catheter bag and tubing exposed.
Both the bag and the tubing contained visible urine. An interview with the Nursing Home Administrator on May 27, 2026, at 10:11 AM, revealed that Resident 4's catheter bag should have been covered with a dignity bag. 28 Pa.
Code 211.12 (b) (1) (2) (5) Nursing services
396111 05/28/2026
Concordia at Spiritrust Utz Terrace 2100 Utz Terrace Hanover, PA 17331
Review of the facility May Activity Calendar revealed a cooking activity on May 13, 2026, at 2:00 PM.
During a staff interview with the Nursing Home Administrator (NHA) on May 27, 2026, at 10:30 AM, he confirmed that the last cooking activity was on May 13, 2026, as per the Activity Calendar. He further indicated that he had removed the key from the lock box in the Activity Director's office and was in the process of writing a policy to address the safe use of the stove.
During a final staff interview with the NHA on May 27, 2026, at 1:06 PM, he confirmed that he would have expected the power to the stove to be turned off when staff are not present, but that he believed that there would not be a resident in that area unattended. 28 Pa.
Code 201.18(b)(1)(3) Management.28 Pa.
Code 211.10(d) Resident care policies.
Observation on the service kitchen on May 26, 2026, at 10:04 AM, with Employee 10 (Dietary Aide) revealed an uncovered serving rack of plates stored upright sitting directly under a window with an air conditioning unit present and running.
Employee 10 indicated that this kitchen area had gotten so hot and that maintenance had just recently placed the unit there to help.
Employee 10 said that staff do turn the unit off when serving food because it blows directly onto the food.
Observation of a refrigerator located in the dining room by the beverage dispenser on May 26, 2026, at 10:10 AM, revealed a black colored splatter in the back of the refrigerator and a black colored spill in the bottom of the refrigerator.
During an immediate staff interview with Employee 14 (Dietary Aide), she said that dietary staff wipe it down when they have time.
Observation of the nourishment area near the main nursing desk on May 26, 2026, at 10:17 AM, revealed individual packets of jellies, salad dressings, and hot chocolate packets that had no dates noted on the packaging. In addition, the refrigerator was noted to have small brown colored spills on a shelf and in the bottom.
During a staff interview with Employee 5 (Dietary Manager) on May 27, 2026, at 10:32 AM, he confirmed that the spices and seasoning should be discarded after six months and indicated that they were a little behind. In addition, Employee 5 acknowledged that he was aware that the air conditioning unit in the service kitchen was blowing over dishes and that he had reported this concern.
During a tray line observation in the service kitchen on May 27, 2026, at 11:50 AM, Employee 10 was observed using her gloved hands to pick up the paper tray tickets, then touch the eating surface of plates twice, push spaghetti noodles back onto plate twice, and pick up garlic roll once.
During an immediate staff interview with Employee 10 and Employee 5, both acknowledged the observations and confirmed that sanitary conditions were not followed.
During a final staff interview with the Nursing Home Administrator on May 27, 2026, at 1:04 PM, he confirmed that he would expect food to be stored, prepared, and served in sanitary manner as well as appropriate sanitation of equipment. 28 Pa.
Code 201.14 Responsibility of licensee.28 Pa.
Code 201.18(b)(1)(3) Management.28 Pa.
Code 211.6(f) Dietary services.
396111 05/28/2026
Concordia at Spiritrust Utz Terrace 2100 Utz Terrace Hanover, PA 17331
Review of Resident 43's clinical record revealed diagnoses that included pseudomonas aeruginosa (a major cause of serious, potentially fatal infections in hospitalized patients, individuals with weakened immune systems) and chronic obstructive pulmonary disease (COPD- a progressive, inflammatory lung disease that restricts airflow and causes breathing difficulties).
Observation of Resident 43 on May 27, 2026, at 9:39 AM, revealed Resident 43 sitting in his room.
Hanging on the wall outside of Resident 43's room was a sign indicating that Resident 43 was on contact precautions and that anyone entering the room was required to put on gloves and a gown and then remove the gloves and gown before exiting the room.
Further observation at that time revealed Employee 3 entering the room without applying any of the required PPE (personal protective equipment) to administer Resident 43's medications.
Review of Resident 43's care plan failed to reveal a care plan regarding Resident 43's need for contact precautions.
Interview with the Nursing Home Administrator (NHA) on May 28, 2026, at 1:10 PM, revealed an expectation that staff would use the correct PPE when entering residents' rooms that require it. A review of the facility policy, titled Water Management Policy, last reviewed April 1, 2026, stated the purpose is to reduce the risk for Legionnaires disease and other water pathogens associated with building water systems and devices based on the risk assessment as outlined below.
Maintaining water temperatures outside the ideal range for Legionella growth (greater than 140 degrees Fahrenheit)Prevent water stagnation (flush any areas weekly such as rooms that are unoccupied) Ensure adequate disinfection (checking free and total chlorine levelsMaintain devices to prevent sediment, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella The facility water management plan included control measures to minimize the risk of hazardous conditions that can promote growth of Legionella and other waterborne pathogens.
Employee 13 (Director of Buildings and Grounds) presented the log forms that should have been completed.
The control measures included - free chlorine checks at the point of entry (Boiler Room) to be completed daily including hot water and cold-water temperature checks.
Pressure checks of the water system daily.
Additionally, four randomly chosen resident rooms are to have hot and cold-water temperature checks weekly.
Per the facility water management plan, if any control measures are out of limits the Supervisor or Director of Buildings and Grounds will be notified immediately
During an interview with the Employee 13 (Director of Buildings and Grounds), the Employee stated that the facility was unable to provide any documented control measures from July 1, 2025, through January 19, 2026, and added that control measures were not performed because of newly hired employees and a failure to assign the task to any staff from July 1, 2025, through January 19, 2026.
During an interview with the NHA on May 28, 2026, at 10:08 AM, the NHA agreed that the waterborne pathogen control measures should have been assigned and completed based on the facility water management plan. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services28 Pa.
Code 201.14(a) Responsibility of licensee28 Pa.
Code 201.18(b)(1)Management
396111 05/28/2026
Concordia at Spiritrust Utz Terrace 2100 Utz Terrace Hanover, PA 17331
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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.