Cycle 1
Health 2025-11-18 · Fire 2024-11-06
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
York, PA
Spiritrust Lutheran The Village At Sprenkle Drive
4-star overall rating with 3-star inspections with $24,670 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1801 Folkemer Circle, York, PA
(717) 767-5404
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
64
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-01-01
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
0.63
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.95
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
2,138
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.53
Composite VBP score used to determine payment impact.
Payment multiplier
1.0059
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.99
Baseline 19.83% · Performance 18.66% · Measure score 5.99 · Achievement 5.99 · Improvement 3.69
Healthcare-associated infections
6.61
Baseline 6.09% · Performance 5.86% · Measure score 6.61 · Achievement 6.61 · Improvement 1.63
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.86
Baseline 3.52 hours · Performance 3.89 hours · Measure score 2.86 · Achievement 2.86 · Improvement 1.14
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.5% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 8.33% · Lower 95% interval 6.58% |
| Discharge to community | 66.24% |
50.57%
15.7 pts better
|
Better than the National Rate · Eligible stays 81 · Observed rate 64.2% · Lower 95% interval 57.36% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.53% |
95.27%
2.3 pts better
|
Numerator 79 · Denominator 81 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 81 |
| Discharge self-care score | 49.3% |
53.69%
4.4 pts worse
|
Numerator 35 · Denominator 71 |
| Discharge mobility score | 59.15% |
50.94%
8.2 pts better
|
Numerator 42 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 1.23% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 81 · Adjusted rate 1.55% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 2.63% · Lower 95% interval 3.44% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 157 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 59.15% |
56.45%
2.7 pts better
|
Numerator 42 · Denominator 71 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.41% |
96.28%
2.1 pts better
|
Numerator 62 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 8.16% |
25.2%
17 pts worse
|
Numerator 4 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0 |
1.7
1.7 pts better
|
1.9
1.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.2
1.2 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
86.9%
12.2 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 98.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.4% |
93.5%
1.9 pts better
|
95.5%
0.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.2%
1.8 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 4.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
6.5%
5 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 0.0% · Q4 2.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 8.6% |
6.5%
2.1 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.9% · Q3 7.0% · Q4 2.4% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
19.9%
4 pts better
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 16.7% · Q3 11.6% · Q4 12.2% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
18.7%
8.4 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 8.6% · Q3 7.9% · Q4 13.5% · 4Q avg 10.3% · 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 | 24.0% |
19.6%
4.4 pts worse
|
16.3%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.5% · 4Q avg 24.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
18.3%
1.9 pts worse
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 24.4% · Q3 16.2% · Q4 16.2% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
26.4%
4.5 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 41.2% · Q3 19.6% · Q4 27.9% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.3%
0.5 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.4% · Q3 7.2% · Q4 7.9% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
68.9%
24.6 pts better
|
81.7%
11.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.6% · Q2 97.2% · Q3 94.7% · Q4 92.2% · 4Q avg 93.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.3% |
9.8%
8.5 pts better
|
12.0%
10.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.3% · Observed 1.2% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.4% |
68.7%
11.7 pts better
|
79.7%
0.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
23.1%
1 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 19.3% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-06 · Fire 2024-01-04
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Cycle 3
Health 2024-01-04 · Fire 2023-01-19
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-11-06
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 2025-01-17
D · Potential for more than minimal harm
2024-11-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-01-04
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-01-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-04
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 2024-03-13
C · Minimal harm
2024-01-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-13
C · Minimal harm
2024-01-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-13
E · Potential for more than minimal harm
2023-01-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-25
E · Potential for more than minimal harm
2023-01-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-25
C · Minimal harm
2023-01-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-25
C · Minimal harm
2023-01-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-25
C · Minimal harm
2023-01-19
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-25
B · Minimal harm
2023-01-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-25
B · Minimal harm
2023-01-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-12
F · Potential for more than minimal harm
2024-11-06
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-12-28
F · Potential for more than minimal harm
2024-11-06
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-11-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-11-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-11-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-11-06
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 2024-12-28
E · Potential for more than minimal harm
2024-11-06
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 2024-12-28
D · Potential for more than minimal harm
2024-11-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-12-28
D · Potential for more than minimal harm
2024-11-06
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 2024-12-28
D · Potential for more than minimal harm
2024-11-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-28
D · Potential for more than minimal harm
2024-11-06
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-28
D · Potential for more than minimal harm
2024-11-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-28
G · Actual harm
2024-10-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-30
G · Actual harm
2024-10-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-01-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-04
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 2024-03-01
D · Potential for more than minimal harm
2024-01-04
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-03-01
Penalties and ownership
What sits behind the stars
$12,335
2024-10-23
Fine
Fine · fine $12,335
Fine
$12,335
2024-10-23
Fine
Fine · fine $12,335
Fine
Ownership
Bowen, Robert
Corporate Officer · Individual
Combs, Stanley
Corporate Director · Individual
Dunlop, James
Corporate Officer · Individual
Frownfelter, Melissa
Corporate Officer · Individual
Kessler, Stephanie
Corporate Officer · Individual
Neinstedt, William
Corporate Officer · Individual
Peck, Michael
Operational/Managerial Control · Individual
Sarvis, Karly
Operational/Managerial Control · Individual
Smeltzer, Samantha
Corporate Officer · Individual
Stout, Kevin
Corporate Director · Individual
Straley, Edward
Corporate Officer · Individual
Thomas, Angela
Corporate Officer · Individual
Thornton, Brenda
Operational/Managerial Control · Individual
Young, Lawrence
Corporate Director · Individual
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#3
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