Concordia at Spiritrust Gettysburg

In the surveyor’s words

From the most serious findings on record at Concordia at Spiritrust Gettysburg, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 12, 2025

  Based on policy review, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen, walk in freezer, and two of two pantries. Findings include: Review of facility policy, titled Labeling and Dating, last reviewed July 18, 2024, revealed the following: 3. All prepared menu items will be dated (m/d) in compliance of a 3 day 'Use by' date. Day 1 is counted as the day of prep. The item is discarded at the end of day 3 . 4. Any unopened food or beverage item will be discarded by the manufacturer labeled expiration date. Examples of what is considered an expiration date can be preceded by, but are not limited to, Use By, Fresh Through, Sell By, etc. […]

• No harm, potential for more than minimal, patternF558Jun 12, 2025

  Based on review of facility policy, review of facility provided call bell monitoring system reports, and resident and staff interviews, it was determined that the facility failed to ensure a prompt response time to resident call bells for four of four residents reviewed (Residents 2, 3, 4, and 30) between March 10, 2025, through June 10, 2025. Findings include: Review of the facility policy, titled Call Light, Use of, with a last revised date of May 18, 2018, and a last review date of July 18, 2024, revealed All Center team members must be aware of call lights at all times. Answer ALL call lights promptly whether or not you are assigned to the resident. Answer call lights in a prompt, calm, courteous manner. Once care needs are started, call light is turned off. […]

• No harm, potential for more than minimal, patternF691Jun 12, 2025

  Based on review of policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper urostomy care for one of one resident reviewed (Resident 4). Findings include: Review of facility policy, titled Colostomy/Ileostomy Care #066, with revised date of July 2015, and a last review date of June 18, 2024, revealed The following information should be recorded in the resident ' s medical record: 1. The date and time the colostomy/ileostomy care was provided. 2. The name and title of the individual(s) who provided the colostomy/ileostomy care. (The above information is generally documented in the Treatment Record.) 3. […]

• No harm, potential for more than minimal, patternF692Jun 12, 2025

  Based on clinical record review and staff interviews, it was determined that the facility failed to inform the dietician or physician of the non-availability of an ordered nutritional supplement for two of two residents reviewed for nutrition(Residents 31 and 39). Findings include: Review of the clinical record for Resident 31 revealed diagnoses that included diabetes mellitus (body has trouble controlling blood sugar and using it for energy) and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). […]

• No harm, potential for more than minimal, patternF761Jun 12, 2025

  Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure controlled substances were contained in a double locked compartment for one of one medication rooms observed (Arlington Hall), and failed to ensure appropriate labeling of medications when opened for two of two medication carts observed (2-AE and 2-A hall). Findings include: Review of facility policy, titled Accountability of Medications and Controlled Substances, last reviewed July 18, 2024, read, in part, d. Medication storage areas remain locked when not in use. Controlled substances are double locked in the medication carts. Emergency controlled substances are also double locked. […]