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)
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
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
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
1.05
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.00
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.10
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.21
CMS adjusted RN staffing hours
Adjusted total hours
4.59
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,551
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.08
Composite VBP score used to determine payment impact.
Payment multiplier
1.0030
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.92
Baseline 17.94% · Performance 19.15% · Measure score 4.92 · Achievement 4.92 · Improvement 0
Healthcare-associated infections
5.68
Baseline 6.39% · Performance 6.14% · Measure score 5.68 · Achievement 5.68 · Improvement 1.30
Total nurse turnover
4.87
Baseline 65.96% · Performance 43.90% · Measure score 4.87 · Achievement 4.84 · Improvement 4.87
Adjusted total nurse staffing
4.17
Baseline 3.86 hours · Performance 4.26 hours · Measure score 4.17 · Achievement 4.17 · Improvement 1.60
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 8.2% · Lower 95% interval 7.14% |
| Discharge to community | 57.08% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 54.55% · Lower 95% interval 47.4% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 87.04% |
95.27%
8.2 pts worse
|
Numerator 47 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 61.54% |
53.69%
7.9 pts better
|
Numerator 32 · Denominator 52 |
| Discharge mobility score | 57.69% |
50.94%
6.8 pts better
|
Numerator 30 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 54 · Adjusted rate 4.32% |
| Healthcare-associated infections requiring hospitalization | 6.14% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 0% · Lower 95% interval 3.38% |
| Staff COVID-19 vaccination coverage | 4.11% |
8.2%
4.1 pts worse
|
Numerator 6 · Denominator 146 |
| Staff flu vaccination coverage | 22.29% |
42%
19.7 pts worse
|
Numerator 37 · Denominator 166 |
| Discharge function score | 69.23% |
56.45%
12.8 pts better
|
Numerator 36 · Denominator 52 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.22% |
96.28%
0.9 pts better
|
Numerator 35 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 19.35% |
25.2%
5.8 pts worse
|
Numerator 6 · Denominator 31 |
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 · Adjusted 0.7 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| 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 · Adjusted 0.4 · Observed 0.3 · Expected 1.2 · 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 | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| 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 · Q1 3.3% · Q2 3.3% · Q3 3.4% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 7.4% · Q4 3.7% · 4Q avg 2.7% |
| 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 · Q1 6.7% · Q2 3.4% · Q3 0.0% · Q4 3.7% · 4Q avg 3.5% |
| 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 · Q1 20.0% · Q2 17.2% · Q3 11.1% · Q4 7.4% · 4Q avg 14.2% |
| 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 · Q1 19.0% · Q2 21.7% · Q4 31.8% · 4Q avg 24.7% · 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 | 9.2% |
19.6%
10.4 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.2% · Used in QM five-star |
| 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 · Q1 29.6% · Q2 25.9% · Q3 23.1% · Q4 20.0% · 4Q avg 24.8% · 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 2.4% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 6.7% · Q2 3.3% · Q3 3.4% · Q4 3.4% · 4Q avg 4.2% · Used in QM five-star |
| 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 · Q1 24.5% · Q2 33.2% · Q3 42.0% · Q4 20.7% · 4Q avg 30.3% |
| 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 · Q1 3.8% · Q2 0.0% · Q3 4.1% · Q4 7.5% · 4Q avg 3.8% · Used in QM five-star |
| 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 · Q1 83.7% · Q2 88.6% · Q3 89.8% · Q4 90.0% · 4Q avg 88.2% |
| 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 · Adjusted 4.9% · Observed 4.5% · Expected 10.3% · Used in QM five-star |
| 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 · Q1 3.7% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| 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 · 4Q avg 83.0% |
| 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 · Adjusted 13.2% · Observed 11.4% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
Combs, Stanley
Corporate Director · Individual
Dunlop, James
Corporate Director · Individual
Frownfelter, Melissa
Corporate Officer · Individual
Keller, Thomas
Operational/Managerial Control · Individual
Neinstedt, William
Corporate Director · Individual
Pyle, Daniel
Operational/Managerial Control · Individual
Smeltzer, Samantha
Corporate Director · Individual
Stout, Kevin
Corporate Director · Individual
Straley, Edward
Corporate Director · Individual
Thomas, Angela
Corporate Director · Individual
Young, Lawrence
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Homewood Living Plum Creek, Inc
Hanover, PA
5-star overall rating with 4-star inspections with $7,443 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Hanover Hall For Nursing And Rehabilitation
Hanover, PA
2-star overall rating with 2-star inspections with $8,190 in total fines with 18 recent health deficiencies
#3
Autumn Lake Healthcare At Long View
Manchester, MD
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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