Gettysburg, PA

Spiritrust Lutheran The Village At Gettysburg

3-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1075 Old Harrisburg Road, Gettysburg, PA

(717) 334-6204

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

60

Certified beds

Average residents

42

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1984-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.82

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.02

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.30

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.14

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.84

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.79

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.59

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.89

CMS adjusted RN staffing hours

Adjusted total hours

4.47

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

34%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,059

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

60.37

Composite VBP score used to determine payment impact.

Payment multiplier

1.0155

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.03

Baseline 17.84% · Performance 19.56% · Measure score 4.03 · Achievement 4.03 · Improvement 0

Healthcare-associated infections

7.97

Baseline 6.52% · Performance 5.45% · Measure score 7.97 · Achievement 7.97 · Improvement 6.50

Total nurse turnover

7.58

Baseline 43.14% · Performance 32.69% · Measure score 7.58 · Achievement 7.58 · Improvement 5.21

Adjusted total nurse staffing

4.57

Baseline 3.76 hours · Performance 4.38 hours · Measure score 4.57 · Achievement 4.57 · Improvement 2.54

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.21%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 95 · Observed rate 8.42% · Lower 95% interval 6.64%
Discharge to community	54.48%	50.57% 3.9 pts better	No Different than the National Rate · Eligible stays 84 · Observed rate 51.19% · Lower 95% interval 45.16%
Medicare spending per beneficiary	0.65	1.02 0.4 pts better
Drug regimen review with follow-up	97.37%	95.27% 2.1 pts better	Numerator 74 · Denominator 76
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 76
Discharge self-care score	55.74%	53.69% 2.1 pts better	Numerator 34 · Denominator 61
Discharge mobility score	44.26%	50.94% 6.7 pts worse	Numerator 27 · Denominator 61
Pressure ulcers or injuries, new or worsened	3.95%	2.29% 1.7 pts worse	Numerator 3 · Denominator 76 · Adjusted rate 4.14%
Healthcare-associated infections requiring hospitalization	5.45%	7.12% 1.7 pts better	No Different than the National Rate · Eligible stays 59 · Observed rate 0% · Lower 95% interval 3.04%
Staff COVID-19 vaccination coverage	3.06%	8.2% 5.1 pts worse	Numerator 3 · Denominator 98
Staff flu vaccination coverage	47.01%	42% 5 pts better	Numerator 55 · Denominator 117
Discharge function score	50.82%	56.45% 5.6 pts worse	Numerator 31 · Denominator 61
Transfer of health information to provider	95.35%	95.95% 0.6 pts worse	Numerator 41 · Denominator 43
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	26.19%	25.2% 1 pts better	Numerator 11 · Denominator 42

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.7 0.3 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.9	1.2 0.3 pts better	1.8 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	86.9% 13.1 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.6%	93.5% 4.1 pts better	95.5% 2.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6%
Percentage of long-stay residents experiencing one or more falls with major injury	4.3%	3.2% 1.1 pts worse	3.3% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.6% · Q3 6.1% · Q4 3.0% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.4%	6.5% 1.1 pts better	11.4% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.1% · Q3 10.3% · Q4 0.0% · 4Q avg 5.4%
Percentage of long-stay residents who lose too much weight	7.6%	6.5% 1.1 pts worse	5.4% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.8% · Q3 12.5% · Q4 6.5% · 4Q avg 7.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.8%	19.9% 5.1 pts better	19.6% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.1% · Q3 15.6% · Q4 9.4% · 4Q avg 14.8%
Percentage of long-stay residents who received an antipsychotic medication	8.5%	18.7% 10.2 pts better	16.7% 8.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 7.4% · Q3 11.5% · Q4 4.0% · 4Q avg 8.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	30.5%	19.6% 10.9 pts worse	16.3% 14.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.4% · 4Q avg 30.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	31.4%	18.3% 13.1 pts worse	14.9% 16.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 41.9% · Q3 25.9% · Q4 24.1% · 4Q avg 31.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	0.9% 0.2 pts worse	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.7% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.4%	1.7% 0.3 pts better	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	40.8%	26.4% 14.4 pts worse	19.8% 21 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 47.0% · Q2 39.9% · Q3 33.4% · Q4 42.0% · 4Q avg 40.8%
Percentage of long-stay residents with pressure ulcers	1.4%	5.3% 3.9 pts better	5.1% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 2.8% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.6%	68.9% 29.7 pts better	81.7% 16.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 98.6% · Q3 98.7% · Q4 100.0% · 4Q avg 98.6%
Percentage of short-stay residents who had an outpatient emergency department visit	11.4%	9.8% 1.6 pts worse	12.0% 0.6 pts better	Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.0% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.6%	1.5% 0.9 pts better	1.6% 1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	95.9%	68.7% 27.2 pts better	79.7% 16.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.7%	23.1% 3.4 pts better	23.9% 4.2 pts better	Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 19.2% · Expected 23.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-12 · Fire 2025-06-12

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-05-02 · Fire 2024-05-02

3 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2023-07-20 · Fire 2023-07-20

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-06-12

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-08-15

E · Potential for more than minimal harm 2025-06-12

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2025-08-15

E · Potential for more than minimal harm 2025-06-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-08-15

E · Potential for more than minimal harm 2025-06-12

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-08-15

E · Potential for more than minimal harm 2024-05-02

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-02

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-02

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-06-28

C · Minimal harm 2024-05-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-06-28

F · Potential for more than minimal harm 2023-07-20

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-08-11

E · Potential for more than minimal harm 2023-07-20

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-08-11

E · Potential for more than minimal harm 2023-07-20

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-08-11

C · Minimal harm 2023-07-20

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-08-11

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-06-12

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-06-12

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-06-12

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-06-12

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-06-12

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-12

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-12

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-12

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-07-18

E · Potential for more than minimal harm 2024-05-02

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-02

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-02

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-06-18

E · Potential for more than minimal harm 2023-07-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-07-20

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-08-11

D · Potential for more than minimal harm 2023-07-20

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-08-11

D · Potential for more than minimal harm 2023-07-20

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-07-20

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-08-11

D · Potential for more than minimal harm 2023-07-20

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-07-20

F940 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected 2023-08-31

Penalties and ownership