Inspection Reports for Spiritrust Lutheran the Village at Shrewsbury
800 BOLLINGER DRIVE,, SHREWSBURY, PA, 17361
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
62% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 42
Capacity: 68
Deficiencies: 10
Date: Apr 3, 2025
Visit Reason
The inspection was an unannounced partial interim review conducted to verify the full implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction with ongoing compliance measures in place. Several deficiencies related to incident reporting, record confidentiality, medication administration, medication storage, resident assessments, and self-administration of medications were identified and addressed with corrective actions.
Deficiencies (10)
Incident involving staff member displaying concerning behavior was not reported to the Department within 24 hours as required.
Resident's acetaminophen medication label was found unattended, unlocked, and accessible on medication cart.
Resident's annual medical evaluation was not completed timely.
Resident self-administers medications without assessment by a qualified healthcare provider regarding ability and need for reminders.
Medications were dispensed into a cup and left at bedside without physician's order for self-administration; ingestion was not observed.
Prescription medications and syringes were found unlocked, unattended, and accessible in resident rooms and bathrooms.
Medications were not stored properly; blister pack foil was broken, pills exposed, and medication pen unlabeled.
Medication was administered despite blood sugar being below prescribed threshold contrary to prescriber's orders.
Resident assessment was not updated to reflect current need for assistance with mobility using enabler bar.
Resident support plans did not accurately document ability to self-administer medications or need for assistance as ordered.
Report Facts
License Capacity: 68
Residents Served: 39
Current Residents: 42
Total Daily Staff: 45
Waking Staff: 34
Hospice Current Residents: 1
Residents Age 60 or Older: 39
Residents with Mobility Need: 6
Inspection Report
Renewal
Census: 42
Capacity: 68
Deficiencies: 17
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as part of a renewal licensing inspection for SpiriTrust Lutheran The Village at Shrewsbury.
Findings
The inspection identified multiple violations related to medication administration, resident record access and confidentiality, medication storage and labeling, follow-up on prescriber's orders, and documentation deficiencies. A first provisional license was issued due to these violations with a plan of correction required.
Deficiencies (17)
Delayed access to resident records requested by Department agents.
Medication error not reported to the Department when medication was unavailable and not administered.
Resident-specific narcotic medication logbook was unlocked and unattended.
Snow and ice accumulation on an egress deck.
Residents self-administering medications without proper assessment.
Unlicensed direct care staff administered prescription medications without waiver.
Medications and syringes were not locked and accessible to residents not assessed to self-administer.
Discontinued or non-current medications found in medication carts and resident rooms.
Medications not stored according to manufacturer’s instructions, including expired medications and unlabeled opened medications.
Medications and OTC items not labeled with resident's name or required information.
Resident's glucometer not calibrated correctly and inconsistent blood glucose documentation.
Medication records missing special instructions and diagnosis/purpose for medications.
Failure to follow prescriber's orders for medication administration times and medication availability.
Staff administered insulin without completing required Department-approved diabetes education.
Preadmission screening did not include determination that resident's needs could be met by the home.
Resident assessment and support plan not signed by assessor.
Resident support plan did not accurately document ability to self-administer medications.
Report Facts
Inspection dates: 3
Total daily staff: 49
Waking staff: 37
Residents served: 42
License capacity: 68
Number of deficiencies: 17
Inspection Report
Renewal
Census: 50
Capacity: 68
Deficiencies: 6
Date: Feb 21, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of the facility on 02/21/2024.
Findings
The report found multiple deficiencies including refrigerator temperature violations, incomplete annual medical evaluations, unmet dietary needs documentation, medication storage and administration issues, and unsecured resident records. All deficiencies had plans of correction accepted and were implemented by 04/11/2024.
Deficiencies (6)
Refrigerator in Freedom Hall kitchenette measured above required temperature limits (50°F and 45°F).
Residents 1 and 2 had incomplete or missing annual medical evaluations.
Resident 3's mechanical soft diet was not ordered by an authorized medical professional.
Resident 4's blood sugar documentation in the medication administration record did not match glucometer readings.
Resident 3's medication administration records lacked initials of the staff who administered medication.
A red folder containing resident information was found unlocked, unattended, and accessible in the sunroom of Freedom Hall.
Report Facts
License Capacity: 68
Residents Served: 50
Current Residents in Hospice: 2
Total Daily Staff: 59
Waking Staff: 44
Inspection Report
Census: 57
Capacity: 68
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
The inspection was conducted as a partial, unannounced incident investigation at the facility on 09/06/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 57
License Capacity: 68
Current Hospice Residents: 2
Total Daily Staff: 64
Waking Staff: 48
Resident Support Staff: 0
Inspection Report
Plan of Correction
Census: 57
Capacity: 68
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 03/30/2023, followed by a plan of correction submission.
Findings
The facility was found to have staff members making derogatory and vulgar comments toward residents during the evening shift, which was not acceptable behavior. The staff involved were suspended and subsequently terminated, and a mandatory inservice training was scheduled to address abuse, resident care expectations, and staff conduct.
Deficiencies (1)
Staff persons A and B made derogatory comments and used vulgar language in front of residents, violating the requirement that residents be treated with dignity and respect.
Report Facts
License Capacity: 68
Residents Served: 57
Total Daily Staff: 64
Waking Staff: 48
Residents with Mobility Need: 7
Residents with Physical Disability: 3
Inspection Report
Renewal
Census: 58
Capacity: 68
Deficiencies: 8
Date: Aug 9, 2022
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including an unannounced full inspection on 08/09/2022 and 08/10/2022.
Findings
The inspection found multiple deficiencies including failure to report suspected abuse properly, inoperable carbon monoxide alarm, resident neglect, combustible storage violations, medication record inaccuracies, unlabeled medications, improper medication storage procedures, and incomplete resident assessments. Plans of correction were accepted and implemented with follow-up audits and education scheduled.
Deficiencies (8)
Failure to complete and submit the Mandatory Abuse Reporting ACT 13 Form for a reported incident.
Carbon Monoxide Alarm near the kitchen was inoperable due to missing batteries.
Resident neglect observed where a resident was not provided care for more than 14 hours.
Combustible and flammable materials were stored near heat sources and hot water heaters.
Resident 2's medication administration record (MAR) did not include certain medications found in the resident's room.
A bottle of medication in the medication cart was not labeled with a resident's name.
Medications prescribed for several residents were not available in the home on the inspection date.
An initial assessment was not completed within 15 days of admission for Resident 6.
Report Facts
License Capacity: 68
Residents Served: 58
Staffing Hours: 66
Waking Staff: 50
Completion Date: Aug 30, 2022
Inspection Report
Plan of Correction
Census: 54
Capacity: 68
Deficiencies: 1
Date: Jun 23, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation at Spiritrust Lutheran The Village at Shrewsbury on 06/23/2021 and 06/24/2021.
Findings
The submitted plan of correction related to medication administration training was fully implemented and compliance was maintained. The report notes completion of required medication competency testing and ongoing auditing of med techs.
Deficiencies (1)
Staff Person A failed to successfully complete the initial Department-approved medications administration course taken on 7/19/2019.
Report Facts
License Capacity: 68
Residents Served: 54
Total Daily Staff: 60
Waking Staff: 45
Medication Test Score: 48
Skills Demonstration Score: 95
Notice
Capacity: 68
Deficiencies: 0
Date: Jun 11, 2021
Visit Reason
This document serves as a license renewal notification and certificate of compliance for SpiriTrust Lutheran The Village at Shrewsbury Personal Care Home, confirming the facility's renewal application and informing about the requirement for an annual onsite 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: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Plan of Correction
Census: 54
Capacity: 68
Deficiencies: 2
Date: Apr 5, 2021
Visit Reason
The inspection was a follow-up review conducted on 04/05/2021 to determine if the submitted plan of correction for prior deficiencies was fully implemented.
Findings
The submitted plan of correction was determined to be fully implemented. The report details incidents of resident-to-resident sexual assault and outlines the corrective actions including staff re-education, abuse reporting and prevention measures, and ongoing monitoring.
Deficiencies (2)
Resident-to-resident sexual assault incidents were not reported as required by the Older Adult Protective Services Act.
Resident #1 exhibited sexually aggressive behaviors towards multiple residents, which were not adequately addressed in the resident's assessment and behavior monitoring.
Report Facts
License Capacity: 68
Residents Served: 54
Total Daily Staff: 60
Waking Staff: 45
Completion Date: Apr 22, 2021
Inspection Report
Follow-Up
Census: 53
Capacity: 68
Deficiencies: 1
Date: Feb 4, 2021
Visit Reason
The inspection was a follow-up review conducted on 02/04/2021 and 02/05/2021 to verify that the submitted plan of correction was fully implemented following a prior incident-related partial inspection.
Findings
The submitted plan of correction was determined to be fully implemented. Continued compliance must be maintained. The report includes a deficiency related to failure to provide timely assistance to a resident requiring help with transfers and walking.
Deficiencies (1)
On 1/23/21 at about 3:30 pm, Resident 1 requested assistance from a staff person to help get up out of chair. This assistance was not provided until 4:30 pm when the staff person returned and assisted the resident to the bathroom. The resident's assessment and support plan states that the resident requires assistance with transfers and walking.
Report Facts
License Capacity: 68
Residents Served: 53
Total Daily Staff: 60
Waking Staff: 45
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