Inspection Reports for Spiritrust Lutheran the Village at Utz Terrace
2100 UTZ TERRACE,, HANOVER, PA, 17331
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
89% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 41
Capacity: 46
Deficiencies: 1
Date: Sep 10, 2025
Visit Reason
The inspection was conducted as a renewal visit for the facility's license.
Findings
The submitted plan of correction was found to be fully implemented. One deficiency was noted regarding an incomplete annual medical evaluation for Resident #3, which lacked vital signs information. The facility took corrective actions including obtaining missing vital signs, auditing all resident evaluations, and providing staff education.
Deficiencies (1)
Resident #3's current annual medical evaluation did not include height, weight, pulse rate, blood pressure, and temperature.
Report Facts
License Capacity: 46
Residents Served: 41
Total Daily Staff: 41
Waking Staff: 31
Inspection Report
Renewal
Census: 40
Capacity: 46
Deficiencies: 3
Date: Aug 22, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection found deficiencies related to the absence of a carbon monoxide alarm in the boiler room, an overflowing dumpster outside the home, and medication administration errors involving insulin and other prescribed medications. The submitted plan of correction was determined to be fully implemented.
Deficiencies (3)
Carbon Monoxide Alarm required for the boiler room was not observed nearby or installed within appropriate distance of the units.
Dumpster outside the home was observed overflowing with trash.
Medication administration errors including incorrect insulin dosage and missed medication administration for prescribed drugs.
Report Facts
License Capacity: 46
Residents Served: 40
Total Daily Staff: 40
Waking Staff: 30
Current Residents in Hospice: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Buildings and Grounds Supervisor | Named in relation to replacing and relocating the carbon monoxide alarm and developing education on compliance. | |
| PCHA | Responsible for conducting investigations and re-education related to medication administration errors. |
Inspection Report
Renewal
Census: 39
Capacity: 46
Deficiencies: 6
Date: Feb 14, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 02/14/2023 and 02/15/2023.
Findings
The facility was found to have multiple deficiencies including lack of resident notification about video surveillance, uncovered bed enabler posing entrapment hazard, missing thermometer in first aid kits in transport vehicles, unavailable prescribed medication, unreported medication error, and incomplete support plan documentation for bed rail use. All deficiencies had plans of correction submitted and were implemented by 03/24/2023.
Deficiencies (6)
Residents were not informed upon admission that the front entrance and lobby areas are subject to video recording and signs were not posted indicating video surveillance.
Resident #1 had an enabler device on the bed without a cover, posing an entrapment hazard.
The first aid kit in the Subaru Forester used for resident transport did not include a thermometer.
Resident #2's prescribed medication Polyethylene Glycol was not available in the home on 02/15/2023.
Resident #3 did not receive Sodium Chloride medication as scheduled on 02/05/2023 and the medication error was not reported to the prescriber or resident's designated person by 02/15/2023.
The assessment for Resident #1 did not indicate a medical need for the use of bilateral half-length bed rails or a plan to protect the resident from potential dangers of the bed rails.
Report Facts
License Capacity: 46
Residents Served: 39
Total Daily Staff: 40
Waking Staff: 30
Residents Diagnosed with Mental Illness: 20
Residents 60 Years or Older: 39
Residents with Mobility Need: 1
Notice
Capacity: 46
Deficiencies: 0
Date: Sep 1, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Spiritrust Lutheran the Village at Utz Terrace, a Personal Care Home, following receipt of their renewal application dated June 11, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum licensed capacity: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter and certificate of compliance. |
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
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