Inspection Reports for Spiritrust Lutheran the Village at Kelly Drive
750 KELLY DRIVE,, YORK, PA, 17404
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
70% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 42
Capacity: 60
Deficiencies: 7
Date: Jul 15, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license to ensure continued compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies related to food protection, medication management, labeling, storage procedures, medication records, and following prescriber's orders. The facility submitted a plan of correction which was accepted and fully implemented by the follow-up date.
Deficiencies (7)
Eight (3-gallon) containers of ice cream were uncovered in the walk-in freezer.
Discontinued medications were found in the home's medication cart for residents #3 and #4.
Pharmacy labels for medications of residents #1 and #5 did not reflect current orders accurately.
Discrepancies in blood sugar readings and missing medication (Acetaminophen) for resident #4.
Medication administration records lacked initials of staff administering medications for residents #1, #2, and #5.
Resident #3 was not administered Acetaminophen as ordered and Oxycodone was administered less frequently than prescribed.
Resident #4 did not receive Metoprolol due to medication unavailability in the home.
Report Facts
Containers of ice cream uncovered: 8
License Capacity: 60
Residents Served: 42
Total Daily Staff: 42
Waking Staff: 32
Inspection Report
Renewal
Census: 51
Capacity: 60
Deficiencies: 6
Date: Jul 17, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance and licensing status of Spiritrust Lutheran The Village at Kelly Drive.
Findings
The submitted plan of correction was determined to be fully implemented following the inspection. Several deficiencies were identified related to facility maintenance, medication management, and resident record confidentiality, all of which were addressed with corrective actions and ongoing monitoring plans.
Deficiencies (6)
Window in the shower room on the second floor had multiple cracks in the second layer windowpane.
A discontinued medication (Milk of Magnesia) was found in the medication cart.
Discrepancies between blood sugar readings in Resident 2's glucometer and medication administration record.
Medication (Chlora septic lozenges) prescribed for Resident 4 was not available in the home.
Medication record for Resident 3 incorrectly indicated strength of Acetaminophen as 325mg instead of 500mg.
Records for Resident 1 were found unlocked, unattended, and accessible outside the resident's room.
Report Facts
License Capacity: 60
Residents Served: 51
Current Hospice Residents: 2
Total Daily Staff: 51
Waking Staff: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Conrad | Executive Director | Named in relation to findings and corrective actions. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 18, 2022
Visit Reason
The document reports on the Pennsylvania Department of Human Services, Bureau of Human Service Licensing review conducted on 10/18/2022 and 10/19/2022 to determine the status of the submitted plan of correction for the facility.
Findings
The submitted plan of correction was found to be fully implemented, and continued compliance must be maintained.
Notice
Capacity: 85
Deficiencies: 0
Date: Jun 11, 2021
Visit Reason
The document serves as a certificate of compliance and notification of license renewal for SpiriTrust Lutheran The Village at Kelly Drive, a Personal Care Home. It informs the facility that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted within the next twelve months. Enforcement actions will be taken if noncompliance is found during the inspection.
Report Facts
Maximum capacity: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Notice
Capacity: 60
Deficiencies: 0
Date: Oct 21, 2021
Visit Reason
The document serves to notify the facility of the approval for a revised license capacity reduction from 85 to 60 beds, following the facility's request to adjust the use of physical space.
Findings
The Department granted approval for the revised license capacity reduction, with the license expiration date remaining unchanged.
Report Facts
Licensed capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the approval letter for the revised license capacity |
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