Inspection Reports for Spiritrust Lutheran – the Village at Sprenkle Drive
1802 FOLKEMER CIRCLE,, YORK, PA, 17404
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
70% occupied
Based on a August 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 39
Capacity: 56
Deficiencies: 8
Aug 7, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for Spiritrust Lutheran - The Village at Sprenkle Drive.
Findings
The inspection found several deficiencies including a mobility device posing an entrapment hazard, unlocked poisonous materials accessible to residents, lack of a thermometer in a freezer, insufficient emergency drinking water supply, staff training deficiencies related to transportation, lack of access to real-time blood glucose data for a resident, and inconsistencies in resident mobility documentation. All deficiencies had plans of correction accepted and were implemented by early September 2024.
Deficiencies (8)
| Description |
|---|
| Resident #1’s bed had a mobility device with an uncovered opening posing an entrapment hazard. |
| Unlocked spray bottle with a poisonous cleaning substance accessible to residents in the Pin Oak SDCU. |
| Two tubes of toothpaste with poison warnings accessible to Resident #2 in the Pin Oak SDCU. |
| Freezer near Elm 2nd Dining Room lacked a thermometer. |
| Emergency drinking water was not present in Resident #3, #4, and #5 rooms, and no contract with bottled water supplier existed. |
| Staff Member B provided transportation without completing required direct care staff training. |
| Resident #4 did not have access to real-time blood glucose readings or historical data from Dexcom device. |
| Resident #4’s mobility needs were inconsistently documented between assessments and support plans. |
Report Facts
License Capacity: 56
Residents Served: 39
Special Care Unit Capacity: 24
Special Care Unit Residents Served: 12
Residents Diagnosed with Mental Illness: 13
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 20
Emergency Drinking Water Required: 117
Inspection Report
Follow-Up
Census: 41
Capacity: 56
Deficiencies: 2
Apr 26, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility.
Findings
The inspection found violations related to abuse/neglect and direct care staff qualifications. The abuse incident involved a staff member pushing a resident's wheelchair with excessive force, resulting in the staff member's suspension and termination. The direct care staff person lacked required educational qualifications and was terminated. Plans of correction including staff education and audits were implemented and verified.
Deficiencies (2)
| Description |
|---|
| A resident was physically abused when a staff person pushed the resident's wheelchair with excessive force causing distress. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
Report Facts
License Capacity: 56
Residents Served: 41
Special Care Unit Capacity: 24
Special Care Unit Residents Served: 17
Hospice Current Residents: 2
Staff Total Daily: 61
Staff Waking: 46
Inspection Report
Renewal
Deficiencies: 0
Mar 22, 2023
Visit Reason
The Pennsylvania Department of Human Services, Office of Children, Youth and Families conducted an annual licensing inspection of Children's Aid Home Program of Somerset County on March 22 and 23, 2023, as part of the renewal process for the licensing year from July 15, 2022 to July 15, 2023.
Findings
During the inspection, personnel records, child records, regulatory documents including fire drills, physical site inspection, and interviews with staff and children were reviewed. No areas of regulatory noncompliance or deficiencies were found.
Report Facts
Personnel records reviewed: 5
Child records reviewed: 2
Staff interviewed: 2
Children interviewed: 2
Inspection Report
Renewal
Census: 48
Capacity: 56
Deficiencies: 16
Mar 15, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility to assess compliance with licensing requirements and address any complaints.
Findings
The inspection identified multiple deficiencies related to staff training, medication administration, resident assessments, storage procedures, and documentation. The facility submitted plans of correction which were accepted and implemented by the dates noted.
Deficiencies (16)
| Description |
|---|
| Staff Member B did not complete the 1st day orientation until after the date of hire. |
| Staff Member B's first 40 hours of training were not completed until 03/10/2022. |
| Staff Members C and D did not complete and pass the Department-approved direct care training course and competency test until after their dates of hire. |
| Staff Member A lacked documentation for required annual trainings for 2022 including fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, falls prevention, and new population groups. |
| Combustible materials (spray paint) were unsecured and accessible to residents in a kitchenette cabinet. |
| Resident 1's medical evaluation did not have the mobility needs section completed; Resident 2's medical evaluation lacked tuberculosis testing documentation. |
| Resident 3's medications were unsecured in the resident's bedroom. |
| Resident 2 was assessed as not capable of self-administering medication but medication was kept in the resident's room for self-administration. |
| Medication labels for Resident 3 did not match medication administration records in dosage and instructions. |
| Discrepancies in glucometer readings and missing PRN medications for residents. |
| Resident 3 had no documentation that prescribed wound care was performed on specified dates. |
| Resident 3's diet on assessment did not match the physician's special diet indicator. |
| Resident 2's mobility needs were inconsistently documented between assessments. |
| Resident 3's support plan did not accurately document ability to self-administer medications. |
| Cognitive preadmission screening form was not completed for Resident 4 admitted to the special care unit. |
| Confidential resident information was found unsecured on top of a medication cart in an unlocked room. |
Report Facts
License Capacity: 56
Residents Served: 48
Special Care Unit Capacity: 24
Special Care Unit Residents Served: 20
Hospice Residents: 4
Total Daily Staff: 75
Waking Staff: 56
Residents 60 Years or Older: 48
Residents with Mobility Needs: 27
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Renewal
Census: 44
Capacity: 56
Deficiencies: 5
Feb 1, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found several deficiencies including unlocked poisonous materials accessible to residents, overdue resident assessments and support plan reviews, missing signatures on support plans, and a malfunctioning key-locking device on an emergency exit door. Plans of correction were submitted and implemented to address these issues.
Deficiencies (5)
| Description |
|---|
| A one quart bottle of Oxivir TB disinfectant spray was accessible to residents in the Red Oak secure dementia care unit due to an unlocked cabinet door. |
| Resident #2 had not had an annual evaluation for over one year. |
| Resident #1 and Resident #2's support plans were not reviewed quarterly as required. |
| Resident #1 and Resident #3 did not sign and date their support plans as required. |
| The posted code did not open the emergency exit door at the rear of the Red Oak secure dementia unit. |
Report Facts
License Capacity: 56
Residents Served: 44
Special Care Unit Capacity: 24
Special Care Unit Residents Served: 23
Current Hospice Residents: 1
Total Daily Staff: 67
Waking Staff: 50
Notice
Deficiencies: 0
Aug 20, 2021
Visit Reason
This document serves as a waiver approval for an employee at SpiriTrust Lutheran-The Village at Sprenkle Drive to delay completion of certain assisted living administrator training and orientation requirements due to scheduling of required courses and competency tests.
Findings
The waiver is granted under conditions including attendance at an orientation course, completion of a 15-hour training course, passing a competency test, documentation of training, and supervision by a qualified administrator until training requirements are met. The Department will review compliance during the annual inspection.
Report Facts
Training hours: 15
Orientation course date: Sep 1, 2021
Training course dates: Aug 20, 2021
Training course dates: Aug 21, 2021
Notice
Capacity: 56
Deficiencies: 0
Aug 17, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Spiritrust Lutheran - The Village at Sprenkle Drive Assisted Living Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice confirming the facility's compliance and the issuance of a regular license.
Report Facts
Maximum licensed capacity: 56
Special Care Unit capacity: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
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