Hanover, PA

Spiritrust Lutheran The Village At Utz Terrace

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

2100 Utz Terrace, Hanover, PA

(717) 637-0633

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

40

Certified beds

Average residents

35

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2007-06-18

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.05

Registered nurse staffing

LPN hours / resident day

1.05

Licensed practical nurse staffing

Aide hours / resident day

1.90

Nurse aide staffing

Weekend hours

3.60

Weekend nurse staffing

RN turnover

46%

Annual RN turnover

Total nurse turnover

53%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.7
1.7
1 pts better
1.9
1.2 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 0.4
1.2
0.8 pts better
1.8
1.4 pts better
Long Stay · 20240701-20250630
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
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
93.5%
6.5 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 2.5%
3.2%
0.7 pts better
3.3%
0.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 2.7%
6.5%
3.8 pts better
11.4%
8.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 3.5%
6.5%
3 pts better
5.4%
1.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 14.2%
19.9%
5.7 pts better
19.6%
5.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 24.7%
18.7%
6 pts worse
16.7%
8 pts worse
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened 9.2%
19.6%
10.4 pts better
16.3%
7.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 24.8%
18.3%
6.5 pts worse
14.9%
9.9 pts worse
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents with a urinary tract infection 4.2%
1.7%
2.5 pts worse
1.7%
2.5 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 30.3%
26.4%
3.9 pts worse
19.8%
10.5 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 3.8%
5.3%
1.5 pts better
5.1%
1.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 88.2%
68.9%
19.3 pts better
81.7%
6.5 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 4.9%
9.8%
4.9 pts better
12.0%
7.1 pts better
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 1.7%
1.5%
0.2 pts worse
1.6%
0.1 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 83.0%
68.7%
14.3 pts better
79.7%
3.3 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 13.2%
23.1%
9.9 pts better
23.9%
10.7 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-30 · Fire 2025-04-30

4 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 2 Health 2024-05-16 · Fire 2024-05-16

2 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-05-25 · Fire 2023-05-25

4 health deficiencies

Top issue: Administration (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-04-30

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-05-15

E · Potential for more than minimal harm 2025-04-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-15

E · Potential for more than minimal harm 2025-04-30

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2025-05-15

E · Potential for more than minimal harm 2024-05-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-31

B · Minimal harm 2023-05-25

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-06-12

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-04-30

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 2025-05-30

D · Potential for more than minimal harm 2025-04-30

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-04-30

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-04-30

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 2025-05-30

D · Potential for more than minimal harm 2024-05-16

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 2024-06-13

D · Potential for more than minimal harm 2024-05-16

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-13

E · Potential for more than minimal harm 2023-05-25

F868 · Administration Deficiencies

Health

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

Corrected 2023-06-26

E · Potential for more than minimal harm 2023-05-25

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2023-06-26

D · Potential for more than minimal harm 2023-05-25

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-06-26

D · Potential for more than minimal harm 2023-05-25

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 2023-06-26

Penalties and ownership

What sits behind the stars

Ownership

Bowen, Robert

Corporate Director · Individual

0% 5 facilities 2007-02-13
Combs, Stanley

Corporate Director · Individual

0% 4 facilities 2024-01-01
Dunlop, James

Corporate Director · Individual

0% 5 facilities 2014-03-03
Frownfelter, Melissa

Corporate Officer · Individual

0% 4 facilities 2022-02-01
Keller, Thomas

Operational/Managerial Control · Individual

0% 2 facilities 2025-11-01
Neinstedt, William

Corporate Director · Individual

0% 4 facilities 2022-01-01
Pyle, Daniel

Operational/Managerial Control · Individual

0% 1 facilities 2022-02-01
Smeltzer, Samantha

Corporate Director · Individual

0% 4 facilities 2023-01-01
Stout, Kevin

Corporate Director · Individual

0% 4 facilities 2024-01-01
Straley, Edward

Corporate Director · Individual

0% 4 facilities 2023-01-01
Thomas, Angela

Corporate Director · Individual

0% 4 facilities 2023-01-01
Young, Lawrence

Corporate Director · Individual

0% 4 facilities 2024-01-01

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