Concordia at Spiritrust Utz Terrace

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812May 28, 2026

  Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food safety in the kitchen; failed to store clean dishes in a sanitary manner in one of one service kitchen; failed to provide a sanitary condition in the main kitchen, one of one nourishment room refrigerator, and one of one dining room refrigerators; and failed to serve food in a sanitary manner during one of one tray service line observations. Findings include: Review of facility policy, titled Date Marking for Food Safety Procedure, with a last revised date of September 11, 2025, and a last review date of April 1, 2026, revealed, in part, 2. […]

• No harm, potential for more than minimal, patternF880May 28, 2026

  Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implement transmission-based precautions to prevent the spread of infection for one of three residents (Residents 43) on transmission-based precautions; failed to perform control measures that include daily/weekly temperature checks, water system pressure, disinfectant testing of chlorine levels in the boiler room; and failed to perform weekly water temperature checks for the entire facility from July 1, 2025, through January 19, 2026.Findings Include: Review of facility policy, titled Transmission-Based (Isolation) Precautions, revised April 2, 2024, revealed, Contact Precautions- Donning personal protective equipment (PPE) upon room entry… […]

• No harm, potential for more than minimal, patternF868May 25, 2023

  Based on document review and staff interview, it was determined that the facility failed to ensure the quality assessment and assurance committee consists of the minimum required members for three of three quarterly meeting sign-in documents reviewed (October 2022, January 2023, and April 2023). Findings Include: Review of the facility's attendance record for the months of October 2022, January 2023, and April 2023 revealed no record of participation by the facility's Infection Preventionist. An interview with the Nursing Home Administrator on May 23, 2023, at 12:58 PM, revealed the facility had no qualified Infection Preventionist on staff at that time and during those meetings. 28 Pa. Code 201.14 (a) Responsibility of licensee

• No harm, potential for more than minimal, patternF882May 25, 2023

  Based on interviews, employee training documents, and regulations, it was determined that the facility failed to have an Infection Preventionist (IP) that completed the approved program for specialized training in infection prevention and control to obtain final certificate with 19.3 CEU (continuing education units). Findings include: The Centers for Medicare and Medicaid Services regulation S483.80(b)(4) states, The facility must designate one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's IPCP (Infection Prevention Control Program) that have completed specialized training in infection prevention and control. […]

• No harm, potential for more than minimal, patternF812Jun 9, 2022

  Based on observation, document review, and staff interview, it was determined that the facility failed to ensure food is prepared and distributed in accordance with professional standards for food service safety for one of two kitchen areas reviewed (facility kitchenette). Findings Include: Review of the facility's policy, titled Use of Hair Restraints recently revised September 2021, reads Dining service staff must wear hair restraints as a preventative measure against the spread of illness and to prevent hair from contacting exposed food. Observations in the facility's kitchenette area on June 6, 2022, at 6:41 PM, revealed Dining Service Aides 1 and 2 performing duties without the use of hair restraints. […]