Inspection Reports for Spiritrust Lutheran the Village at Luther Ridge
2735 LUTHER DRIVE,, CHAMBERSBURG, PA, 17202
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
83% occupied
Based on a October 2024 inspection.
Census over time
Inspection Report
Renewal
Census: 30
Capacity: 36
Deficiencies: 8
Date: Oct 22, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 10/22/2024 to review compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies related to staff training, hot water temperature exceeding limits, medication storage and administration errors, incomplete preadmission screening forms, and inconsistencies in resident support plans. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Deficiencies (8)
Direct Care Staff Member A did not receive training in instruction on meeting the needs (DME & RASP), personal care service needs of the resident, and safe management techniques during training year 2023.
Staff Member A did not receive training in resident rights and the Older Adult Protective Services Act (OAPSA) during training year 2022 to 2023.
Hot water temperatures exceeded 120°F in multiple locations including A Wing Common Bathroom (122.6°F), Resident Bedroom #3 (123.0°F), and B Wing Common Bathroom (125.7°F) on 10/22/24.
Resident #1’s glucometer reading did not match the MAR on 10/04/24, showing 128 versus 193 respectively.
Resident #1’s prescribed Accuchecks and Humalog insulin administration were not properly followed on 10/15/24, with missing glucometer reading and insulin dose.
Resident #2’s preadmission screening form did not include a determination that the resident's needs can be met by the services provided by the home.
Resident #1’s medical assessment and support plan contained inconsistent documentation regarding mobility needs and emergency evacuation assistance.
Resident #2 and Resident #3 had mobility devices securely installed and covered on their beds, but their assessments and support plans did not indicate a need for these devices nor document how the need would be met.
Report Facts
License Capacity: 36
Residents Served: 30
Hot Water Temperature: 122.6
Hot Water Temperature: 123
Hot Water Temperature: 125.7
Staffing: 32
Waking Staff: 24
Residents with Mobility Need: 2
Inspection Report
Renewal
Census: 32
Capacity: 36
Deficiencies: 4
Date: Jul 3, 2023
Visit Reason
The inspection was conducted for renewal and complaint reasons as part of a full, unannounced review of the facility.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies were identified related to direct care staff qualifications, medication storage and security, prescription currency, and confidential record handling, all of which had corrective actions accepted and implemented.
Deficiencies (4)
Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Resident medications and syringes were found unlocked, unattended, and accessible in residents' bedrooms.
An expired prescription medication was found in the home's medication cart.
Delivery logs for resident medications were unlocked, unattended, and accessible at the nurse station.
Report Facts
License Capacity: 36
Residents Served: 32
Total Daily Staff: 34
Waking Staff: 26
Residents with Mobility Need: 2
Residents Age 60 or Older: 32
Inspection Report
Renewal
Census: 31
Capacity: 36
Deficiencies: 3
Date: May 18, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included a missing antiseptic in the first aid kit of a transport vehicle and incorrect documentation of glucometer readings for two residents in the Medication Administration Record (MAR).
Deficiencies (3)
The first aid kit in the white Toyota van does not include antiseptic.
Incorrect documentation of glucometer readings for Resident 1 in the Medication Administration Record (MAR).
Incorrect documentation of glucometer readings for Resident 2 in the Medication Administration Record (MAR).
Report Facts
License Capacity: 36
Residents Served: 31
Total Daily Staff: 31
Waking Staff: 23
Glucometer reading errors for Resident 1: 7
Glucometer reading errors for Resident 2: 4
Notice
Capacity: 36
Deficiencies: 0
Date: Oct 21, 2021
Visit Reason
The document serves as a certificate of compliance and approval for a revised license capacity for SpiriTrust Lutheran The Village at Luther Ridge, reducing the licensed capacity from 48 to 36.
Findings
The Department approved the facility's request to reduce its licensed capacity from 48 to 36, with the license expiration date remaining unchanged.
Report Facts
Licensed capacity: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the approval letter for the revised license capacity. |
Notice
Capacity: 48
Deficiencies: 0
Date: Sep 18, 2021
Visit Reason
This document serves as a certificate of compliance and license renewal notification for Spiritrust Lutheran the Village at Luther Ridge, a Personal Care Home, confirming the facility's authorized capacity and informing about the upcoming annual inspection within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
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