Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

CONCORDIA AT SPIRITRUST SPRENKLE DRIVE

YORK, PA · 104 certified beds · Last Life Safety survey November 6, 2024

CMS Certification Number 395612 · first certified January 1984

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

15
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
8
Inspection & testing records
Of the citations on file

Position within PA

15 citations — more than 69% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (September 2025 to November 2025), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was November 2024. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.

This facility15PA median10National median11
Citations on file over three years, compared
MeasureCitations
This facility15
Median facility in PA10
Median facility nationally11

Survey history

Citations at each Life Safety survey
72023-0152024-0132024-11
Citations at each Life Safety survey
Survey dateCitations
January 19, 20237
January 4, 20245
November 6, 20243

Most-cited tags

Most-cited tags at this facility
K-03212K-03451K-07121K-02111K-09141K-01001K-03631K-09181
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.22024-11-06
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12024-01-04
K-0712Have simulated fire drills held at unexpected times.12023-01-19
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12024-11-06
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.12023-01-19
K-0100Meet other general requirements.12024-01-04
K-0363Install corridor and hallway doors that block smoke.12024-11-06
K-0918Have generator or other power source capable of supplying service within 10 seconds.12024-01-04

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 7
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Egress Deficiencies 2
  • Construction Deficiencies 2
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies7
Gas, Vacuum, and Electrical Systems Deficiencies3
Egress Deficiencies2
Construction Deficiencies2
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

November 6, 2024 — 3 citations

Citations issued on November 6, 2024
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (January 17, 2025)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (January 17, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (January 17, 2025)

January 4, 2024 — 5 citations

Citations issued on January 4, 2024
TagWhat the surveyor checksStatus
K-0100Meet other general requirements.Deficient, Provider has date of correction (March 13, 2024)
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (March 13, 2024)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (March 13, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (March 13, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (March 13, 2024)

January 19, 2023 — 7 citations

Citations issued on January 19, 2023
TagWhat the surveyor checksStatus
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (March 25, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (March 25, 2023)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (March 25, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (March 25, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (March 25, 2023)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (March 25, 2023)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (March 25, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.