Pennsylvania Department of Health
CONCORDIA AT SPIRITRUST LUTHER RIDGE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CONCORDIA AT SPIRITRUST LUTHER RIDGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights survey and abbreviated health survey completed on June 11, 2026, it was determined that Spiritrust Lutheran, The Village at Luther Ridge was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician orders were followed for catheter care for one of one resident reviewed for catheters (Resident 8).

Findings include:

Facility policy, titled "Catheter Care, Urinary," last reviewed January 2026, read, in part, "The purpose of this procedure is to prevent infection of the resident's urinary tract. Catheter care is to be done every shift and as necessary."

Review of Resident 8's clinical record revealed diagnoses that included dementia (decline in mental ability severe enough to interfere with daily life) and obstructive and reflux uropathy (blockage of the urinary tract that causes urine to back up into one or both kidneys).

Review of Resident 8's physician orders revealed an order for foley catheter: document color, clarity, sediment, odor every shift related to obstructive and reflux uropathy.

Review of Resident 8's treatment administration records for May 2026 and June 2026 revealed that there was no documentation for foley catheter: document color, clarity, sediment, odor every shift on the following dates and shifts: day shift May 2, 3, 4, 6, 12, 27, and June 1; evening shift - May 1, 2, 3; and night shift May 1, 2, 3.

Review of Resident 8's point of care tasks revealed a task for catheter care every shift and as needed.

Further review of Resident 8's task for catheter care for May 2026 and June 2026 revealed that there was no documentation that any catheter care was provided for the following dates and shifts: day shift May 31 and June 2; evening shift - May 9, 30; and night shift - May 5, 6, 16, 24, 28, 30, 31 and June 4.

During an interview with the Nursing Home Administrator (NHA) on June 11, 2026 at 10:09 AM, it was revealed that she had no additional information to provide. The NHA stated that it was the facility's expectation that physician orders be followed, that documentation be completed, and that catheter care be provided.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 08/10/2026

Correction does not constitute an admission of or an agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

Current patients have the potential to be affected. The DON and/or designee will complete an audit on 6/30/2026 of current patients with orders for urinary catheters to determine if there are any other affected patients. Identified patients from this initial audit will have immediate corrective action taken for the nursing documentation to include color, clarity, sediment and odor of urine.

DON/Designee will educate RN's, LPN's, CNA's on the Federal Regulation 0690 and on the facility's documentation requirement for urine collected by a catheter to include color, clarity, sediment, odor and performing and documenting catheter care.

The DON and/or designee will audit 5 Residents with orders for catheters weekly to ensure required documentation is completed x 4 weeks and 5 residents randomly x 2 months. Findings will be reported to Quality Assurance Committee for review and recommendations.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for three of five residents reviewed (Residents 4, 7, and 8).

Findings Include:

Facility policy, titled "Drug Regimen Review," last reviewed January 2026, read, in part, "PROCEDURE: 1. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, physician and the care planning team. 2. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review (approximately 30 days) ...3. Recommendations are acted upon and documented by the facility staff and/or the prescriber ...5. The Director of Nursing keeps the consultant pharmacist's monthly reports on file for at least one year (annual survey to annual survey)."

Review of Resident 4's clinical record revealed diagnoses that included type 2 diabetes mellitus (the body resists the effects of insulin or doesn't produce enough insulin, causing high blood sugar) and atherosclerotic heat disease of native coronary artery (blood vessel supplying the heart becomes narrowed or blocked by plaque).

Review of the pharmacy's medication regimen review documents failed to reveal documentation that Resident 4's medication had been reviewed for the months of July 2025, August 2025, October 2025, February 2026, March 2026, and May 2026.

Further review of the pharmacy medication regimen review documents revealed recommendations were made April 2026.

Review of the recommendations on the aforementioned date failed to reveal a physician response or signature.

An interview with the Nursing Home Administrator (NHA) on June 11, 2026 at 10:05 AM, revealed that the facility had no additional information to provide and that it was the facility's expectation that pharmacy medication reviews to be completed monthly and recommendations be responded to timely by the physician.

Review of Resident 7's clinical record revealed diagnoses that included dementia (decline in mental ability severe enough to interfere with daily life) and anxiety disorder (persistent and excessive worry or fear that is disproportionate to the situation and interferes with daily life).

Review of the pharmacy's medication regimen review documents failed to reveal documentation that Resident 7's medication had been reviewed for the months of July 2025, August 2025, September 2025, October 2025, December 2025, and January 2026.

Further review of the pharmacy medication regimen review documents revealed recommendations were made on March 12, 2026, and April 23, 2026.

Review of the recommendations on the aforementioned dates failed to reveal a physician response or signature.

An interview with the NHA on June 11, 2026 at 10:05 AM, revealed that the facility had no additional information to provide and that it was the facility's expectation that pharmacy medication reviews to be completed monthly and recommendations be responded to timely by the physician.

Review of Resident 8's clinical record revealed diagnoses that included dementia and anxiety disorder.

Review of the pharmacy's medication regimen review documents failed to reveal documentation that Resident 8's medication had been reviewed for the months of July 2025, September 2025, and October 2025.

Further review of the pharmacy medication regimen review documents revealed that recommendations were made on August 19, 2025; January 19, 2026; and April 23, 2026.

Review of the recommendations on the aforementioned dates failed to reveal a physician response or signature.

An interview with the NHA on June 11, 2026 at 10:05 AM, revealed that the facility had no additional information to provide and that the NHA would expect pharmacy medication reviews to be completed monthly and pharmacy recommendations to be reviewed and responded to in a timely manner by the physician.

28 Pa. code 211.9 (a)(1) Pharmacy services
28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Plan of Correction - To be completed: 08/10/2026

Correction does not constitute an admission of or an agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
The facility is currently having the pharmacy consultant complete monthly medication reviews. The facility is currently having the physicians respond to the monthly consultant pharmacy reviews.
Current patients have the potential to be affected. The facility will complete an audit on the consultant pharmacy medication reviews for the month of June to validate each current patient had a pharmacy consultant review and the attending physician addressed the recommendations made by the consultant pharmacist.
DON/Designee will educate the physicians the facility's policy Drug Regime Review.
The DON and/or designee will complete a weekly audit x 4 weeks and randomly x 2 months to validate monthly consultant pharmacist reviews are being addressed by the attending physicians. Findings will be reported to Quality Assurance for review and recommendations.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide ongoing assessment and monitoring for one of one residents reviewed receiving dialysis (Resident 41).

Findings include:

A review of the facility policy, titled "Hemodialysis Resident Care Standard," last reviewed January 2026, revealed that staff were to complete the pre-dialysis portion of the Hemodialysis Communication Record that provided information regarding the resident's ongoing status to send with the resident to dialysis. The policy stated, "Assure the interchange of information with the dialysis clinic useful/necessary for the care of the resident. Use Hemodialysis Communication Form (#806NSG)."

Clinical record review revealed that Resident 41 had diagnoses that included end-stage renal (kidney) disease and dependence on renal dialysis, and had a physician's order dated May 19, 2026, for the facility to provide dialysis three days per week. There was a lack of evidence to support that the pre-dialysis portion of the Resident's dialysis communication forms were completed or that the Resident was assessed before dialysis prior to any dialysis since May 19, 2026.

A staff interview with Employee 1 (Registered Nurse) on June 10, 2026, at 11:25 AM, revealed there was no dialysis communication binder or folder for documentation to or from the dialysis center for Resident 41. Employee 1 said the family transports Resident 41 to and from dialysis and there was no documentation returned with the Resident or family to the facility.

On June 10, 2026, the surveyor requested post-dialysis communication forms. The facility was unable to provide any post-dialysis communication forms.

On June 11, 2026, at 10:10 AM, the surveyor was provided with copies of documentation from dialysis. The post-dialysis forms were never sent to the facility or requested by the facility until June 11, 2026.

During an interview with the Nursing Home Administrator (NHA) on June 11, 2026, at 10:07 AM, regarding the facility Dialysis Policy not being followed for Resident 41, the NHA expressed the expectation for staff to follow the policy for effective communication with Dialysis regarding resident care pre and post dialysis treatments.

28 Pa. Code 211.12(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 08/10/2026

Correction does not constitute an admission of or an agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
Resident #41 had the hemodialysis communication form initiated on 6/09/2026.
Current dialysis patients have the potential to be affected. The facility will complete an audit of current patients receiving dialysis treatments to validate communication form is being utilized. Identified patients without the hemodialysis communication form in place will have the communication tool in place for their next scheduled dialysis treatment.

DON/Designee will educate RN's and LPN's on Federal Regulation 0698 and the facility policy entitled Hemodialysis Resident Care Standard. Nursing staff identified as not following the facility policy will have progressive discipline.

The DON and/or designee will audit current patients with hemodialysis orders to validate the communication form is being utilized with each dialysis treatment. This audit will be conducted weekly x 4 weeks and randomly x 2 months. Findings will be reported to Quality Assurance for review and recommendations.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 12 residents reviewed (Residents 4 and 7).

Findings include:

Facility policy, titled "Comprehensive Care Planning Standard," last reviewed January 2026, read, in part, "PROCEDURE: A. The care plan framework will include the following: 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being."

Review of Resident 4's clinical record revealed diagnoses that included type 2 diabetes mellitus (the body resists the effects of insulin or doesn't produce enough insulin, causing high blood sugar) and pressure ulcer of the right buttock, stage 3 (full-thickness skin wound, exposing the underlying fatty tissue).

Review of Resident 4's weekly wound rounds notes revealed that Resident 4 had a chronic stage 3 pressure injury on the right buttock, acquired on August 1, 2025, and that Resident 4 was currently receiving treatment for the pressure injury.

Review of Resident 4's comprehensive plan of care failed to reveal a focus area or interventions for skin impairment or pressure ulcer.

During an interview with the Nursing Home Administrator (NHA) on June 11, 2026, at 10:05 AM, it was revealed that a focus area for skin impairment to include pressure ulcer and interventions had been added to Resident 4's care plan. The NHA stated it was the expectation of the facility that comprehensive care plans be developed accurately.

Review of Resident 7's clinical record revealed diagnoses that included dementia (decline in mental ability severe enough to interfere with daily life) and anxiety disorder (persistent and excessive worry or fear that is disproportionate to the situation and interferes with daily life).

Review of Resident 7's physician orders revealed medication orders for oxycodone (narcotic pain medication), Ativan (psychotropic, anti-anxiety medication), quetiapine fumarate (anti-psychotic medication), and escitalopram oxalate (psychotropic antidepressant medication).

Further review of Resident 7's physician orders revealed an order for hospice evaluation and treatment.

Review of Resident 7's comprehensive care plan failed to reveal any focus areas or interventions for receiving hospice services, antipsychotic medication use, narcotic medication use, and psychotropic medication use.

During an interview with the NHA on June 11, 2026 at 10:05 AM, it was revealed that a new company had taken over on May 1, 2026, and that the facility was in the process of updating resident records. The NHA stated that Resident 7's comprehensive care plan had not been completed in the new company's system. The NHA stated it was the expectation of the facility that comprehensive care plans be developed in a timely manner.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(3)(5) Nursing services

Plan of Correction - To be completed: 08/10/2026

Correction does not constitute an admission of or an agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
DON and Social Services updated Care plans for Resident 4 and 7 during survey.
Facility completed an audit on current patients in house on 6/24/26 to validate comprehensive careplans were in place for those patients. Patients identified with missing careplans will have careplans developed immediately completed by the interdisciplinary team. Any new changes identified for current residents will be captured and updated on careplans.
DON/Designee will educate Social Services, Wound Nurse, RNAC, RN's, LPN's on Federal Regulation 0656 Comprehensive Care Plans.
DON/Designee will audit to ensure a person-centered comprehensive care was developed on all admissions and 5 current residents weekly x 4 weeks and 5 residents randomly x 2 months. Findings will be reported to Quality Assurance Committee for review and recommendations.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that a discharge summary was completed for one of three closed clinical records reviewed (Resident 50).

Findings include:

A Review of Pennsylvania Department of Health Long Term Care Facility Regulations (28 Pa. Code 211.5(d) Medical records) states:
"Records of discharged residents shall be completed within 30 days of discharge. Medical
information pertaining to a resident's stay shall be centralized in the resident's record.
A resident's medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death, and (iv) Medical and nursing history and physical examination reports."

Review of Resident 50's clinical record revealed a diagnoses of chronic respiratory failure (respiratory system cannot take in enough oxygen or remove enough carbon dioxide from the blood) and chronic obstructive pulmonary disease (progressive lung disease that causes obstructive airflow from the lungs, making it difficult to breathe).

Review of Resident 50's clinical record revealed the Resident was pronounced deceased on March 15, 2026, while Emergency Medical Services was attempting to transport the Resident to the hospital.

Review of Resident 50's clinical record on June 10, 2026, revealed no discharge summary in the closed medical record.

During an interview with the Nursing Home Administrator (NHA) on June 10, 2026, at 12:10 PM, the NHA confirmed a Discharge Summary was never completed or it would be present in the closed record.

Plan of Correction - To be completed: 08/10/2026

Correction does not constitute an admission of or an agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
Facility is completed discharge summaries on closed records.
NHA/Designee will conduct a 30-day lookback audit to validate Physician Summaries were completed on closed records for that 30day lookback period. Identified closed clinical records without physician discharge summaries will have the summaries completed immediately by the physician.
DON/Designee will educate Physician on PA State regulation 4880 Medical Records.
The DON and/or Designee will complete an audit weekly x 4 and randomly x 2 months on closed records to validate physician discharge summaries are completed according to the PA State Regulation 4880. Findings will be reported to Quality Assurance for review and recommendation.

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