SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE
Non profit - Corporation
40 Beds
Independent
Data: November 2025
Trust Grade
60/100
#356 of 653 in PA
Photo by SpiriTrust Lutheran, The Village at Luther Ridge
Photo by SpiriTrust Lutheran, The Village at Luther Ridge
Photo by SpiriTrust Lutheran, The Village at Luther Ridge
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Spiritrust Lutheran The Village at Luther Ridge has a Trust Grade of C+, which means it is slightly above average but still has room for improvement. It ranks #356 out of 653 facilities in Pennsylvania, placing it in the bottom half of the state, and #4 out of 6 in Adams County, indicating only one local option is better. The facility's performance is worsening, with issues increasing from 6 in 2024 to 9 in 2025. Staffing is a positive aspect, as it has a turnover rate of 0%, which is significantly better than the state average. However, there have been concerns regarding medication management; for instance, the facility failed to notify practitioners about missed medication doses for several residents and did not ensure that medications were administered according to professional standards. Overall, while there are strengths in staffing and no fines, the increasing number of issues and specific medication management failures are concerning.
- Trust Score
- C+
- In Pennsylvania
- #356/653
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ✓ Good
- Each resident gets 78 minutes of Registered Nurse (RN) attention daily — more than 97% of Pennsylvania nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Bottom 46%
No red flags
6 → 9 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 9 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Pennsylvania average (3.0)
Meets federal standards, typical of most facilities
The Ugly 24 deficiencies on record
May 2025
9 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on facility policy review, clinical record review, review of facility documents, and resident and staff interviews, it was determined that the facility failed to report an allegation of abuse an...
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Based on facility policy review, clinical record review, review of facility documents, and resident and staff interviews, it was determined that the facility failed to report an allegation of abuse and/or neglect to the required agencies in a timely manner for two of two residents reviewed (Residents 6 and 17).
Findings include:
Review of facility policy, titled Abuse/Neglect Exploitation Prevention Standard for Skilled Care, with a last revised date of October 4, 2017, and a last review date of May 21, 2025, revealed, in part, physical abuse is defined as, but not limited to, hitting, slapping, pinching, kicking, or handling in a rough manner; neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness; the willful deprivation by a caretaker of goods and services which are necessary to maintain physical or mental health; the Administrator/designee notifies the local Area Agency on Aging of the allegation immediately; in addition, any allegations of sexual abuse, physical abuse involving serious physical injury, serious bodily injury, or suspicious death are reported immediately to state survey agency no later than two hours after forming the suspicion, If no serious bodily injury is involved, the timeframe for reporting a reasonable suspicion is within 24 hours.
Review of Resident 6's clinical record revealed diagnoses that included muscle weakness, Charcot's joint of right ankle/foot (condition characterized by joint damage due to loss of sensation), and chronic non-pressure ulcer of the right heel.
During a resident interview with Resident 6 on May 27, 2025, at 10:21 AM, Resident 6 indicated that she had experienced a fall from the mechanical sit to stand lift. She further indicated that she believed the nurse aide did not have her in the lift correctly.
Review of Resident 6's care plan revealed a care plan focus for at risk for falls due to limited mobility, right Charcot joint to foot/ankle with a last revision date of January 19, 2022; and activities of daily living impaired due to weakness, medical comorbidities, and limited to extensive assistance with most tasks, with a last revision date of December 29, 2022. Interventions included, but were not limited to, transfer assistance of two with a mechanical sit to stand lift with an initiated date of February 1, 2023.
Review of Resident 6's clinical record revealed a nursing note dated May 4, 2025, at 9:45 AM, that indicated Resident had a witnessed fall earlier this AM, with a CNA [nurse aide] in room. CNA was changing resident brief, while using stand lift, and resident slid out of stand lifts secure device and fell to the floor.
Review of facility provided incident report dated May 4, 2025, for Resident 6's fall indicated that Resident 6 fell during a brief change with a nurse aide while using stand-up lift and had no noted injury. Resident 6's description of the event indicated the same. The incident investigation determined that the nurse aide providing care neglected to follow Resident 6's care plan for assistance of two staff and neglected to follow facility policy, which required the use of two team members with a mechanical lift.
The facility documentation failed to reveal any reports to any of the required agencies to include the local Area Agency on Aging and state survey agency.
During a staff interview with the Nursing Home Administrator (NHA) on May 29, 2025, at 12:04 PM, she confirmed Resident 6's fall was the result of the nurse aide neglecting to follow Resident 6's care plan and the facility policy. She confirmed that the facility did not report Resident 6's fall as a result of neglect to any of the required agencies, and indicated that it should have been reported to all the required agencies.
Review of facility provided grievance log for May 2025 revealed that Resident 17 filed a grievance on May 14, 2025, which indicated that a staff member had kicked him.
Review of the facility provided grievance form and investigation revealed that the Director of Nursing was notified on May 13, 2025, at 7:33 PM, that Resident 17 alleged that the nurse aide providing his care that evening had kicked his foot a few months ago when he had a fall to get him to stand up.
The documentation provided for review revealed that the facility completed an investigation and found that the abuse was unsubstantiated. Facility documentation failed to reveal any reports to any of the required agencies to include the local Area Agency on Aging and state survey agency.
During a staff interview with the NHA on May 29, 2025, at 12:06 PM, she confirmed that based on the nature of Resident 17's allegation of physical abuse, it should have been reported to the required agencies.
28 Pa. Code 201.14(a)(c) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 14 residents reviewed (Residents 6 and 8).
Findings include:
Review of facility policy, titled Comprehensive Care Planning Standard, with a last revised date of November 17, 2017, and a last review date of May 21, 2025, revealed E. The Care Plan is reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments; and L. Care plans are evaluated and revised as the resident's status changes and with any goals or treatment refusals.
Review of Resident 6's clinical record revealed diagnoses that included long term use of anticoagulants (blood thinning medication used to prevent/reduce blood clot formation), chronic total occlusion of the artery to the lower extremities, and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
Review of Resident 6's care plan revealed a care plan focus for potential for bleeding/bruising due to aspirin and Plavix (a medication used to prevent platelets from forming clots) use, dated April 30, 2021.
Review of Resident 6's clinical record revealed that she was hospitalized from [DATE]-25, 2025, and that her Plavix and aspirin were discontinued upon her return to the facility.
Review of Resident 6's clinical record also revealed that she had an admission 5 Day MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) with the assessment reference date (last day of the assessment period) of March 27, 2025, completed with a subsequent care plan review.
During an interview with the Nursing Home Administrator (NHA) on May 29, 2025, at 12:02 PM, she indicated that Resident 6's care plan should have been revised when it was reviewed upon Resident 6's return to the facility or after her comprehensive assessment and subsequent care plan review.
Review of Resident 8's clinical record revealed clinical diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture) and Spondylosis (age-related wear and tear of the spinal disks).
Review of Resident 8's clinical record revealed the Resident had a fall with major injury on May 14, 2025.
A fall risk evaluation was completed on May 23, 2025, that revealed a score of 13, indicating the Resident is high risk for falls.
A review of Resident 8's care plan revealed no current focus on risk for falls, and further review revealed the fall care plan was marked as RESOLVED on May 23, 2025.
During an interview with the NHA on May 29, 2025, at 12:14 PM, the NHA confirmed that a fall care plan should be present on the care plan.
42 CFR 483.21(b)(2) Comprehensive Care Plans
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on facility policy review, clinical record review, facility documentation review, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision an...
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Based on facility policy review, clinical record review, facility documentation review, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of two residents reviewed for falls (Resident 6).
Findings include:
Review of facility policy, titled Risk Management Incident/Accident Reporting Standard, with a last revised date of November 28, 2017, and a last review date of May 21, 2025, revealed the facility identifies potential safety hazards, identifies residents at risk for accidents and/or falls and adequately plans care and implements procedures to prevent accidents.
Review of facility policy, titled Resident Fall Prevention/ Prevention of Injury Standard, with a last revised date of November 28, 2017, and a last review date of May 21, 2025, revealed Residents will receive appropriate preventative measures and intervention to reduce risk for falls or injury; and Each member of the community, including team members, volunteers, and family members will support the safety of the residents' environment.
Review of facility policy, titled Limited Lift Environment Standard, with a last revised date of August 7, 2015, and a last review date of May 21, 2025, revealed F. Resident Transfer-Responsibilities: When a mechanical lift is used, two (2) team members are required.
Review of Resident 6's clinical record revealed diagnoses that included muscle weakness, Charcot's joint of right ankle/foot (condition characterized by joint damage due to loss of sensation), and chronic non-pressure ulcer of the right heel.
During a resident interview with Resident 6 on May 27, 2025, at 10:21 AM, Resident 6 indicated that she had experienced a fall from the mechanical sit to stand lift. She further indicated that she believed the nurse aide did not have her in the lift correctly.
Review of Resident 6's care plan revealed a care plan focus for at risk for falls due to limited mobility, right Charcot joint to foot/ankle with a last revision date of January 19, 2022; and activities of daily living impaired due to weakness, medical comorbidities, and limited to extensive assistance with most tasks with a last revision date of December 29, 2022. Interventions included, but were not limited to, transfer assistance of two with a mechanical sit to stand lift with an initiated date of February 1, 2023.
Review of Resident 6's clinical record revealed a nursing note dated May 4, 2025, at 9:45 AM, that indicated Resident had a witnessed fall earlier this AM, with a CNA [nurse aide] in room. CNA was changing resident brief, while using stand lift, and resident slid out of stand lifts secure device and fell to the floor.
Review of facility provided incident report dated May 4, 2025, for Resident 6's fall indicated that Resident 6 fell during a brief change with a nurse aide while using stand-up lift and had no noted injury. Resident 6's description of the event indicated the same. The incident investigation determined that the nurse aide providing care failed to follow Resident 6's care plan for assistance of two staff and failed to follow facility policy, which required the use of two team members with a mechanical lift.
During a staff interview with the Nursing Home Administrator on May 29, 2025, at 12:04 PM, she indicated that she was unsure why the nurse aide was attempting to change Resident 6's brief while having her positioned in the sit to stand lift. She confirmed that the aide did not follow Resident 6's care plan or facility policy, which resulted in a fall. She indicated that she would expect staff to follow a resident's care plan and facility policies.
201.4(a) Responsibility of licensee
201.18(b)(1) Management
211.10(d) Resident care policies
211.12(d)(1)(2)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on facility policy review, clinical record reviews, and staff interview, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity w...
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Based on facility policy review, clinical record reviews, and staff interview, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for two of five residents reviewed for unnecessary medications (Residents 6 and 27).
Findings include:
Review of facility policy, titled Drug Regimen Review, with a last revised date of February 2023, and a last review date of May 21, 2025, revealed Drug regimen review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication; and 3. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to a recommendation directed to him/her within a reasonable time frame, the Director of Nursing, designee and/or the consultant pharmacist may contact the Medical Director.
Review of Resident 6's clinical record revealed diagnoses that included knee pain and muscle weakness.
Review of Resident 6's drug regimen review for February 18, 2025, revealed a pharmacist recommendation to review Resident 6's medication order for Voltaren/diclofenac gel (a topical nonsteroidal anti-inflammatory drug [NSAID] used for the temporary relief of joint pain associated with osteoarthritis) for the following identified concern to assist in administering this gel the manufacturer provides a dosing card. The proper amount of Voltaren gel should be measured using the dosing card supplied. The recommended dosing is 2gm[grams] for each elbow, wrist, or hand, and 4 gm for each knee ankle, or foot. Please clarify the order to include this dose. Orders with 'apply 1 application' or simply 'apply' are not specific enough. This recommendation was not reviewed or signed by Resident 6's physician.
Review of Resident 6's drug regimen review for March 24, 2025, revealed that the pharmacist made the exact same recommendation as February 18, 2025, since Resident 6's physician had failed to respond. On this recommendation Resident 6's physician marked Disagree. No change indicated, Current Benefit Outweighs Potential Risk and signed and dated the form April 1, 2025. No order change was given.
Review of Resident 6's current orders revealed an order for Diclofenac Sodium External Gel 3 % (Diclofenac Sodium) Apply to bilateral knees topically every 6 hours as needed for mild to mod pain, dated January 20, 2023, indicating that Resident 6 still had a medication order that failed to include a physician ordered dose to administer.
Review of 27's clinical record revealed diagnoses that included muscle weakness and right shoulder pain.
Review of Resident 27's drug regimen review for February 18, 2025, revealed a pharmacist recommendation to review Resident 27's medication order for Voltaren/diclofenac gel for the following identified concern to assist in administering this gel the manufacturer provides a dosing card. The proper amount of Voltaren gel should be measured using the dosing card supplied. The recommended dosing is 2gm[grams] for each elbow, wrist, or hand, and 4 gm for each knee ankle, or foot. Please clarify the order to include this dose. Orders with 'apply 1 application' or simply 'apply' are not specific enough. This recommendation was not reviewed or signed by Resident 27's physician.
Review of Resident 27's drug regimen review for March 24, 2025, revealed that the pharmacist made the exact same recommendation as February 18, 2025, since Resident 27's physician had failed to respond. On this recommendation Resident 27's physician marked Disagree. No change indicated, Current Benefit Outweighs Potential Risk and signed and dated the form April 1, 2025. No order change was given.
Review of Resident 27's current orders revealed an order for Diclofenac Sodium External Gel 1 % (Diclofenac Sodium) Apply to right shoulder topically every 12 hours as needed for shoulder pain, dated February 16, 2025, indicating that Resident 27 still had a medication order that failed to include a physician ordered dose to administer.
During a staff interview with the Nursing Home Administrator on May 29, 2025, at 12:02 PM, she confirmed that Resident 6's and 27's physician should have provided an order for the correct dose of Voltaren/diclofenac gel for nursing staff to administer.
28 Pa. Code 211.2(d)(3) Medical Director
28 Pa. Code 211.9(d) Pharmacy services
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on surveyor observations, facility policy, and staff interviews, it was determined that the failed to place opened dates on medications in one of two medication rooms (Arlington Unit) observed.
...
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Based on surveyor observations, facility policy, and staff interviews, it was determined that the failed to place opened dates on medications in one of two medication rooms (Arlington Unit) observed.
Findings Include:
Review of facility policy, titled Multi-Dose Medication Storage, with a revision date of May 21, 2025, read, in part, Facility will date multi-dose vials when opened, for the purpose of infection control and to ensure product stability.
Observation of the medication storage room refrigerator on May 29, 2025 at 11:00 AM, with Employee 1, revealed two open multi dose vials of Tuberculin solution (a sterile solution, primarily Purified Protein Derivative (PPD), used for diagnosing tuberculosis) with no open dates.
During a staff interview with Employee 1 on May 29, 2025, at 11:00 AM, it was revealed that multidose vials should be dated when opened.
During a staff interview on May 29, 2025 at 11:58 AM, with the Nursing Home Administrator (NHA), the NHA stated that it was the facility's expectation that multidose vials be dated when opened.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1) Pharmacy services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on review of the sign-in sheets for the facility's Quality Assurance Performance Improvement (QAPI) Committee and staff interview, it was determined that all the required members failed to atten...
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Based on review of the sign-in sheets for the facility's Quality Assurance Performance Improvement (QAPI) Committee and staff interview, it was determined that all the required members failed to attend at least one meeting in one out of three quarterly meetings.
Findings include:
Review of all available documentation submitted by the facility revealed that there was not one meeting within the fourth quarter of 2024 in which all required attendees attended. The Medical Director was not in attendance at the October 16, 2024, meeting; the Director of Nursing nor the Medical Director were present at the November 20, 2024, meeting; and the Infection Preventionist nor one additional facility staff member were present at the December 18, 2024, meeting.
During an interview with the Nursing Home Administrator (NHA) on May 29, 2025, at approximately 12:06 PM, the NHA indicated that the facility QA committee meets monthly. She confirmed that there was no one meeting in the fourth quarter of 2024 that had all required attendees present. She further indicated that she would expect all required members to be in attendance at least one of the monthly QAPI meetings in a quarter.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on review of personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of...
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Based on review of personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for two of five nurse aide employee records reviewed (Employees 2 and 3).
Findings include:
Review of facility provided training records for Employee 2 revealed that she only completed 10 hours of the 12 required hours of annual training in the past 12 months.
Review of facility training records for Employee 3 revealed that she only completed 6 hours of the 12 required hours of annual training in the past 12 months.
During an interview with the Nursing Home Administrator on May 29, 2025, at 11:07 AM, she confirmed that she would expect nurse aides to meet required training hours.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 201.19(7) Personnel policies and procedures
28 Pa. Code 201.20(a) Staff development
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the practitioner was notified of missed medic...
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Based on policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the practitioner was notified of missed medication administration when medications were unavailable for four of 13 residents reviewed (Residents 12, 14, 15, and 19) and failed to provide treatment in accordance with professional standards of practice and physician orders for one of 13 residents reviewed (Resident 25).
Findings include:
Review of facility policy, Medication Administration, last revised June 2023, revealed, If a medication is not available, staff will notify the pharmacy provider immediately. Notify resident and/or resident representative and provider if a missed dose would occur.
Review of Resident 12's clinical record revealed diagnoses that included type II diabetes mellitus (condition characterized by high blood sugar levels due to insulin resistance and relative lack of insulin production) and central pain syndrome (chronic condition characterized by ongoing pain due to issues with the nervous system, often resulting from damage to the brain or spinal cord).
Review of Resident 12's May 2025 MAR (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Gabapentin (used to treat nerve pain) three times per day for central pain syndrome.
Further review of the MAR revealed that nursing staff documented that Gabapentin was not administered on May 17, 2025 (three missed doses) and on May 18, 2025 (three missed doses).
Review of Resident 12's clinical record failed to reveal evidence that the practitioner was notified of the missed medication administrations.
During an interview with the Nursing Home Administrator (NHA) on May 29, 2025, at 1:37 PM, she confirmed that she was unable to locate evidence that the practitioner was notified Resident 12's missed doses of Gabapentin.
Review of the clinical record for Resident 14 revealed clinical diagnoses that included hospice (end of life status) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).
A review of Resident 14's current care plan revealed the Resident had a psychosocial well-being problem
related to her diagnosis of anxiety.
Review of Resident 14's physician orders reveal that the Resident was ordered Lorazepam (antianxiety medication) 0.5 milligrams twice a day for anxiety.
Review of Resident 14's progress notes and medication administration record on October 14, 2025, at 7:00 PM; October 15, 2025, at 7:30 AM and 7:00 PM; and on October 16, 2025, at 7:30 AM and 7:00 PM, revealed the medication was not available to be administered as ordered for anxiety. There was no documentation in the progress notes that the physician was notified of the missed doses of Lorazepam.
During an interview with the NHA on May 28, 2025, at approximately 1:00 PM, the NHA confirmed there was no documentation to confirm that the physician was notified about the missed doses of Lorazepam.
Review of Resident 15's clinical record revealed diagnoses that included congestive heart failure (condition that happens when the heart cannot pump blood well enough to meet the body's needs) and shortness of breath.
Review of Resident 15's May 2025 MAR revealed an order for Torsemide (diuretic) in the afternoon for congestive heart failure.
Further review of Resident 15's MAR revealed that Torsemide was not administered on May 24, 2025.
Review of Resident 15's clinical record failed to reveal evidence that the practitioner was notified of the missed medication administration.
During an interview with the NHA on May 29, 2025, at 1:37 PM, she confirmed that she was unable to locate evidence that the practitioner was notified Resident 15's missed dose of Torsemide.
Review of Resident 19's clinical record revealed diagnoses that included congestive heart failure and hypothyroidism (condition where the thyroid gland doesn't produce enough thyroid hormone leading to a slow down in metabolism).
During an interview with Resident 19 on May 27, 2025, at 10:54 AM, she expressed concern over an incident where she had gone without her levothyroxine (synthetic thyroid hormone) because it was not available to administer to her.
Review of Resident 19's April 2025 MAR revealed an order for levothyroxine daily for hypothyroidism.
Further review of Resident 19's MAR revealed that levothyroxine was not administered on April 10 and 11, 2025.
Review of Resident 19's clinical record failed to reveal evidence that the practitioner was notified of the missed medication administration.
During an interview with the NHA on May 29, 2025, at 1:37 PM, she confirmed that she was unable to locate evidence that the practitioner was notified Resident 19's missed doses of levothyroxine.
Review of Resident 25's clinical record revealed diagnoses that included charcot's joint, ankle and foot (a degenerative joint disorder characterized by progressive bone and joint destruction due to nerve damage), and gout (a form of inflammatory arthritis characterized by sudden, severe pain and swelling in the joints).
Observations made on May 27, 2025 at 12:29 PM, and May 28, 2025, at 9:41 AM, revealed a brace on Resident 25's right lower extremity.
Review of Resident 25's physician orders failed to reveal orders for right lower extremity splint application or care.
Review of Resident 25's progress notes, medication administration record, and treatment administration record failed to reveal documentation of Resident 25's right lower extremity splint.
Review of Review of Resident 25's care plan failed to reveal a focus area or intervention for a right lower extremity splint.
During an interview on May 29, 2025, with the Nursing Home Administrator (NHA) it was revealed that physician orders were now in place for Resident 25's right lower extremity splint and a care plan had been developed. The NHA stated it was the expectation of the facility that orders and a care plan would be in place.
201.14(a) Responsibility of licensee
201.18(b)(1) Management
211.12(d)(1)(2)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for ...
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Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for four of 17 residents reviewed (Residents 12, 14, 15, and 19).
Findings Include:
Review of facility policy, Medication Administration, last revised June 2023, revealed, Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice.
Review of Resident 12's clinical record revealed diagnoses that included type II diabetes mellitus (condition characterized by high blood sugar levels due to insulin resistance and relative lack of insulin production) and central pain syndrome (chronic condition characterized by ongoing pain due to issues with the nervous system, often resulting from damage to the brain or spinal cord).
Review of Resident 12's May 2025 MAR (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Basaglar subcutaneous solution (insulin) at bedtime for diabetes mellitus as well as an order for Gabapentin (used to treat nerve pain) three times per day for central pain syndrome.
Further review of the MAR revealed that nursing staff documented that Basaglar was not adminstered on May 3, 2025; and Gabapentin was not administered on May 17, 2025 (three missed doses) and on May 18, 2025 (three missed doses).
Review of corresponding nursing progress notes revealed the following:
May 3, 2025 - Resident is to receive 14 units of Basaglar Kwikpen . No insulin pen found, including in omnicell. Per MAR, insulin pen is on order. ;
May 16, 2025 (regarding Gabapentin) - Called pharmacy and reordered medication due to administering the last one and none being left in the cart or anywhere on the unit 30 day supply (quantity of 90) should arrive this evening.
May 17, 2025 (regarding Gabapentin) - Waiting for med to arrive from pharmacy. Med out of stock in the omnicell also. and still waiting to come from pharmacy, and
May 18, 2025 (regarding Gabapentin) - waiting for pharmacy to bring, None in stock. and not received from pharmacy. out of stock in omincelle and Waiting for med from pharm.
During an interview with the Nursing Home Administrator (NHA) on May 29, 2025, at 1:37 PM, she confirmed that Resident 12's medications were not administered as ordered.
Review of the clinical record for Resident 14 revealed clinical diagnoses that included hospice (end of life status) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).
Review of Resident 14's physician orders reveal that the Resident was ordered Lorazepam (antianxiety medication) 0.5 milligrams twice a day for anxiety.
Review of Resident 14's progress notes and medication administration record on October 14, 2025, at 7:00 PM; October 15, 2025, at 7:30 AM and 7:00 PM; and on October 16, 2025, at 7:30 AM and 7:00 PM, revealed the medication was not available to be administered as ordered for anxiety.
During an interview with the NHA on May 28, 2025, at approximately 1:00 PM, the NHA confirmed the medication was not available due to a change in pharmacies. The NHA added that the new pharmacy delivered the electronic medication unit (Omnicell) on the evening of October 14, 2025, but there was no access to the unit because staff had to be trained on the new unit.
Review of Resident 15's clinical record revealed diagnoses that included congestive heart failure (condition that happens when the heart cannot pump blood well enough to meet the body's needs) and shortness of breath.
Review of Resident 15's May 2025 MAR revealed an order for Torsemide (diuretic) in the afternoon for congestive heart failure.
Further review of Resident 15's MAR revealed that Torsemide was not administered on May 24, 2025.
Review of corresponding nursing progress notes revealed that Resident 15's Torsemide was not administered due to awaiting pharmacy.
During an interview with the NHA on May 29, 2025, at 1:37 PM, she confirmed that Resident 15's medications were not administered as ordered.
Review of Resident 19's clinical record revealed diagnoses that included congestive heart failure and hypothyroidism (condition where the thyroid gland doesn't produce enough thyroid hormone, leading to a slow down in metabolism).
During an interview with Resident 19 on May 27, 2025, at 10:54 AM, she expressed concern over an incident where she had gone without her levothyroxine (synthetic thyroid hormone) because it was not available.
Review of Resident 19's April 2025 MAR revealed an order for levothyroxine daily for hypothyroidism.
Further review of Resident 19's MAR revealed that levothyroxine was not administered on April 10 and 11, 2025.
Review of corresponding nursing progress notes revealed the following: April 10, 2025 - Medication not available. Awaiting arrival from pharmacy, and on April 11, 2025 - medication not available. continue to wait for medication from pharmacy.
During an interview with the NHA on May 29, 2025, at 1:37 PM, she confirmed that Resident 19's medications were not administered as ordered.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Jul 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on policy review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were repo...
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Based on policy review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported immediately for one of one resident abuse reports reviewed (Resident 38).
Findings include:
Review of facility policy, titled Abuse/Neglect Exploitation Prevention Standard for Skilled Care, revised October 4, 2017, revealed, Allegations of abuse or neglect may be reported by any individual having knowledge of or perceiving that a situation of abuse, exploitation or neglect has occurred. Team members working in the retirement communities are considered 'mandatory' reporters .Allegations in the skilled center will be reported to the skilled care center administrator, Director of Nursing, or designee immediately.
Review of facility's electronic incident report submission and associated documents, dated March 25, 2024, revealed that it was reported by Employee 3 that while Employees 3 and 4 (Nurse Aides) were providing care to Resident 38 on March 21, 2024, Resident 38 was screaming uncontrollably in anxiety, and Employee 4 said to Resident 38 in her ear with aggression Stop yelling, there are people out there in dining room trying to eat! Did you care when you had them up all the night before that they are tired? Employee 4 then took a wash cloth and at least twice ran it over Resident 38's face in an attempt to hush her. When Resident 38 began to scream more, Employee 4 placed her fingers in the resident's mouth and then nose while mocking the Resident's noises and voice. Further review of the incident report submission revealed that following Employee 3's report of alleged abuse, a second staff member, Employee 6 (Nurse Aide), reported an additional allegation of abuse that occurred on March 18, 2024, where Employee 4 sprayed Resident 38 in the face with water during her bath.
Review of Employee 5's (Registered Nurse Supervisor) witness statement dated March 24, 2024, revealed that Employee 3 reported the alleged incident that occurred on March 21, 2024, to her on March 24, 2024. Further review of Employee 5's witness statement revealed that Employee 6 also came to her on that date and reported a separate incident involving Employee 4 and Resident 38.
Review of Employee 6's witness statement, dated March 24, 2024, revealed that on March 18, 2024, around 10:00 AM, she and Employee 4 were bathing Resident 38. Resident 38 was worked up but nothing different than usual. Employee 4 was visually and vocally frustrated with Resident 38 and her behavior. Employee 4 used the handle sprayer twice to spray Resident 38 in the face.
During an interview with the Director of Nursing on July 25, 2024, at 1:55 PM, she revealed the expectation that the aforementioned allegations of abuse should have been reported timely.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet ...
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Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 15 residents reviewed (Resident 18).
Findings Include:
Review of Resident 18's clinical record revealed diagnoses that included congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and localized edema (swelling caused by excess fluid accumulation in the body tissues).
Review of Resident 18's June and July 2024 TARs (Treatment Administration Records - forms used to document physician orders as well as when and how treatments are administered to a resident) revealed an order for daily weights; call provider if weight gain of more than three pounds in a day, or more than five pounds in a week. This order was effective June 19, 2024. Further review of Resident 18's TARs revealed that no weight, or refusal to be weighed, was recorded on June 23 and 30, 2024, or on July 14 and 16, 2024. Additionally, weights recorded on July 3 and 10, 2024, indicated a weight gain of greater than three pounds from the prior day (6.5 pounds on July 3, 2024; and 4.2 pounds on July 10, 2024), but review of available clinical documentation failed to reveal that the practitioner was notified of the weight gain on either date.
During an interview with the Director of Nursing on July 25, 2024, at 1:55 PM, she revealed that she did not have any additional information regarding the missed weights or practitioner notification of weight gain.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on clinical record review, policy review, and staff and resident interviews, it was determined that the facility failed to ensure each resident received treatment in accordance with professional...
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Based on clinical record review, policy review, and staff and resident interviews, it was determined that the facility failed to ensure each resident received treatment in accordance with professional standards of practice for one of one resident reviewed (Resident 32) receiving dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidney can no longer perform these functions naturally).
Findings Include:
A review of the facility policy, titled Hemodialysis Resident Care Standard, last reviewed July 19, 2024, stated that the facility will assure safe medical management of residents who receive dialysis in a dialysis clinic, outside of the facility.
Review of Resident 32's clinical record revealed diagnoses that included end stage renal disease (kidneys can no longer filter waste and excess fluids) and atrial fibrillation (irregular and rapid heartbeat).
During an interview on July 22, 2024, at 10:00 AM, with Resident 32 it was revealed that that the Resident receives dialysis treatment three times a week at an outside facility.
Review of Resident 32's current physician orders revealed orders for check bruit and thrill at AV fistula (surgically created connection between an artery and a vein that provided access for hemodialysis) site every day and evening shift. Further review of Resident 32's orders revealed there were no physician orders for dialysis treatment, name of facility for dialysis treatment, frequency of dialysis, or contact number for dialysis.
During an interview on July 25, 2024, at 11:00 AM, with the Director of Nursing (DON), the DON confirmed that Resident 32 receives dialysis treatment three days a week and a physician order should have been written that includes receiving dialysis, name of facility for dialysis treatment, frequency, facility and contact information.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident Care Policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews, policy review, and clinical record review, it was determined that the facility failed to document completely and accurately on the clinical records for one of 1...
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Based on observation, staff interviews, policy review, and clinical record review, it was determined that the facility failed to document completely and accurately on the clinical records for one of 15 residents reviewed (Resident 86).
Findings include:
A review of the facility policy, titled Accountability of Medications and Controlled Substances, last reviewed July 17, 2024, informed staff to document the administration of all medications that are administered to residents.
Review of the clinical record for Resident 86 on July 23, 2023, revealed diagnoses that included cellulitis of the lower left limb (a common and potentially serious bacterial skin infection) and hypertension (high/elevated blood pressure).
Observation of Resident 86 on July 22, 2024, at 9:30 AM, revealed an empty bag of Cefazolin (antibiotic) at the bedside that was administered at 8:00 AM on July 22, 2024, per physician orders.
A review of the Resident 86's admission MDS (Minimum Data Set-periodic assessment of resident needs) dated July 16, 2024, revealed the Resident had a BIMS (brief interview of mental status) score of 15 out of a possible score of 15, indicating that he is cognitively intact.
A review of the clinical record revealed that Resident 86 has a physician order for Cefazolin 2 grams intravenously to be administered every 8 hours for cellulitis.
A review of Resident 86's medication administration record revealed the nurse never initialed the doses of Cefazolin on July 16, 2024, at 7:00 PM, or on July 19, 2024, at 4:00 AM. A review of the ordered times also revealed the 7:00 PM dose should have been transcribed at 8:00 PM based on the every 8 hours administration time ordered.
The Director of Nursing (DON) was able to contact the pharmacy to confirm that three doses are delivered daily, and also confirmed there are no extra doses on the unit that weren't administered, and that the Resident hasn't refused any doses.
During an interview with the DON on July 25, 2024, at approximately 11:00 AM, and on July 26, 2024, at approximately 1:15 PM, via telephone correspondence,the DON confirmed that documentation should be complete and transcription of times should be accurate on resident clinical records.
28 Pa. Code 211.12(d)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on facility policy review, observations, and staff interview, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide...
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Based on facility policy review, observations, and staff interview, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents reviewed for transmission based precautions (Resident 14) and one of one residents reviewed for pressure ulcers (Resident 14).
Findings include:
Review of facility policy, titled Corporate Infection Control Policy Manual, with a review date of July 17, 2024, read, in part, Purpose: SpiriTrust Lutheran facilities will maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections .D. Types of Precautions to be used if isolation required: 1. Hand Hygiene: c. If caring for a resident with a C. Difficile infection, do not use alcohol based hand-rub. d. Hands are to be washed: . (2) Before putting on gloves or other PPE such as gowns, masks, goggles, etc . (5) After removal of dirty gloves and before putting on clean gloves during treatments or wound dressings. (6) After removing gloves when finished caring for a resident or their environment. Clostridium Difficile (C. Difficile) 7. Once an active C. Difficile infection has been diagnosed, the following precautions should be followed: a. Standard and Modified Contact Precautions .c. Proper Hand Hygiene following guidelines d. Alcohol-based hand rubs, gels, or foams are not to be used .e. Sign: placed on room door .f. When caring for the resident with C. difficile infection, wash your hands prior to caring for the resident. Wear gloves .wear a gown during care or exposure to contaminated surfaces. After care, wash your hands. G. Enhanced Barrier Precautions (EBP) b. EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: i. Wounds .regardless of MDRO colonization status.
Review of Resident 14's clinical record revealed diagnoses that included infectious gastroenteritis and colitis (contagious inflammation affecting the stomach and intestines), enterocolitis (inflammation of the digestive tract) due to clostridium difficile (c. diff. - highly contagious bacterial infection of the colon), and chronic peripheral venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes).
Review of Resident 14's current physician's orders revealed Resident 14 was receiving oral vancomycin for infectious gastroenteritis and colitis. Further review of Resident 14's physician's orders also revealed Resident 14 had wound care orders for dressing changes to the right ankle, left first and second toe, and sacrum.
Observations of Resident 14's room made on July 22, 2024, at 12:30 PM, and July 23, 2024, at 9:49 AM, failed to reveal signage that indicated contact precautions and EBP were in place, and no personal protection equipment (PPE) was present for use.
Review of Resident 14's comprehensive plan of care revealed a focus area for potential for isolation due to c. diff. with an intervention for I am on contact precautions.
Observation of Resident 14's wound care on July 25, 2024, at 9:24 AM, revealed Employee 7 (Licensed Practical Nurse) failed to preform hand washing prior to donning a gown and gloves. During the wound treatment and dressing change, it was observed that Employee 7 failed to preform hand washing after removing the soiled dressing and donning clean gloves. It was also observed that Employee 7 used alcohol-based hand rub after doffing her gown and gloves and exiting Resident 14's room.
During a staff interview on July 25, 2024, at 1:42 PM, with the Nursing Home Administrator, the Director of Nursing (DON), and Employee 1, the DON revealed signage for contact precaution and EBP were now in place and a PPE caddy had been placed by Resident 14's door. She stated that it was the facility's expectation that signage would have been in place and PPE be available. The DON also stated that it was the facility's expectation that proper hand washing be performed when performing wound care and caring for residents on contact precautions for c. diff.
28. Pa Code 211.12 (d)(1)(5) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a lic...
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Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, that irregularities were reported to the appropriate parties, and that these reports were acted upon in a timely manner for four of five residents reviewed for unnecessary medications (Residents 2, 13, 17, and 29).
Findings include:
Review of facility policy, titled Drug Regimen Review, revised February 2023, revealed, 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) . Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to a recommendation directed to him/her within a reasonable time frame, the Director of Nursing, designee, and/or the consultant pharmacist may contact the Medical Director.
Review of Resident 2's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and delusional disorders (disorder in which a person holds fixed false beliefs and is unable to tell what is real from what is imagined).
Review of Resident 2's Medication Regimen Review form dated November 29, 2023, revealed the following recommendation: Please evaluate the clinical appropriateness and alternative therapy for extended usage of Macrobid [antibiotic]. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner provided a timely response to this recommendation.
Review of Resident 2's Medication Regimen Review form dated January 24, 2024, revealed the following note: I cannot find November's recommendation in the chart. Please evaluate the clinical appropriateness and alternative therapy for extended usage of Macrobid. Further review of the form revealed the practitioner did not respond to the recommendation until March 22, 2024, almost two months following the recommendation date.
Review of Resident 2's Medication Regimen Review form dated June 17, 2024, revealed the following recommendation: Please evaluate the clinical appropriateness and alternative therapy for extended usage of Macrobid. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner reviewed or responded to this recommendation after it was again made.
Review of Resident 13's clinical record revealed diagnoses that included vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory) and delusional disorders.
Review of Resident 13's Medication Regimen Review form dated November 29, 2023, revealed the following recommendation: Please consider D/C [discontinuing] PRN [as-needed] Ondansetron [used to prevent nausea or vomiting]. Resident has not used medication for >60 days. Discontinuing this order will reduce the overall pill burden for the resident. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner provided a timely response to this recommendation.
Review of Resident 13's Medication Regimen Review form dated March 21, 2024, revealed the following recommendation: Hydroxyzine [used to treat itching] started on 2/23/24. Did we consider starting at 12.5 mg? Please evaluate the clinical appropriateness and alternatives to Hydroxyzine. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner reviewed or responded to this recommendation.
Review of Resident 13's Medication Regimen Review form dated June 17, 2024, revealed the following recommendation: The resident has an ACB score of 6 [Anticholinergic Burden Calculator - used to rate risk of adverse events for patients over 65 based on medications taken] . Your patient scored >3 and is therefore at a higher risk of confusion, falls and death .Please consider alternatives to reduce the overall risk for the resident. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner reviewed or responded to this recommendation.
Review of Resident 17's clinical record revealed diagnoses that included dementia (decline in thinking and problem-solving skills) severe with psychotic disturbance and hallucinations (condition causing loss of contact with reality) and mixed anxiety disorders (serious mental health condition causing symptoms of depression and anxiety).
Review of pharmacy medication regimen review documents failed to revealed Resident 17's medication had been reviewed in December 2023.
Further review of the pharmacy medication regimen review documents revealed a review dated January 24, 2024, with a recommendation for the physician that stated a December 2023 recommendation could not be located in the chart and to evaluate and correct the supporting diagnosis for quetiapine. The physician response was dated March 22, 2024.
During a staff interview July 25, 2024, at 12:00 PM, with the Director of Nursing (DON) it was revealed that Resident 17's pharmacy medication regimen review for December 2023 could not be located and that she could not verify that it had been completed.
Review of Resident 29's clinical record revealed diagnoses that included congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and paroxysmal atrial fibrillation (irregular heart rhythm that can cause symptoms such as fatigue, lightheadedness, and stroke).
Review of Resident 29's Medication Regimen Review form dated March 21, 2024, revealed the following recommendation: Please consider changing Colace [stool softener] dosing from 100mg BID [twice daily], to 200mg daily, to reduce the overall pill burden. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner provided a timely response to this recommendation.
During an interview with the DON on July 25, 2024, at 1:55 PM, she revealed the expectation that pharmacy recommendations should have been reviewed and responded to in a timely manner.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Sept 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to implement their established procedures for investigation and protection ...
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Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to implement their established procedures for investigation and protection of residents related in response to potential abuse of two of 12 residents reviewed (Resident 3 and 8).
Findings include:
Review of facility policy, titled Risk Management Incident/Accident Reporting Standard last revised November 28, 2017, revealed, Each Spiritrust Lutheran Skilled Care Community identifies potential safety hazards, identifies residents at risk for accidents and/or falls and adequately plans care and implements procedures to prevent accidents .Completing a thorough investigation into the probable causes of the incident/accident, Planning appropriate interventions to prevent reoccurrence of incidents/accidents, On-going review and revision of Plan of Care interventions as necessary .An incident is defined as any unusual event such as falls, skin tears, bruises, injuries of unknown origin, Following the identified occurrence, and Incident/Accident Report is initiated immediately in the EHR (electronic health record) in the 'Risk Management' section .Abuse investigations and unknown origin investigations require signed witness statements .witnesses are interviewed, verbal statement documented .information dictated verified with witness by licensed nurses/designee prior to saving the statement in EHR, the information requested in the EHR is completed in its entirety.
Review of Resident 3's clinical record revealed diagnoses that included Repeated falls, dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and difficulty walking.
Review of Resident 3's clinical record revealed a nursing note on August 30, 2023, at 10:46 AM, that stated [Nurse Aid] called this nurse into resident's room when she was assisting him in getting dressed. Skin tear noted to upper back of L[eft] arm. Area is 1cm [centimeter-unit of measure] X 1cm. Resident unsure of how he obtained it. Cleansed area with NSS [normal saline solution], applied bacitracin & DSD [dry sterile dressing]. Resident pulling arm away when trying to look at it & when dressing it. Called & left voicemail with POA [Power of Attorney- legal representative] to call back for update. RN [Registered Nurse] notified.
During email correspondence with the Nursing Home Administrator (NHA) on September 12, 2023, at 12:07 PM, the surveyor inquired about an investigation related to Resident 3's skin tear discovered on August 30, 2023.
Interview with Employee 1 (Clinical Excellence Nurse) on September 13, 2023, at 10:27 AM, revealed she does not have any information to provide that an investigation was conducted, and she would expect a thorough investigation to be completed per the facility policy.
During an interview with the NHA on September 14, 2023, at 11:03 AM, the surveyor revealed the concern with the facility's failure to follow established procedures for investigation and protection of residents related in response to potential abuse. The NHA revealed she would expect a thorough investigation to be completed per the facility policy.
Review of Resident 3's clinical record revealed diagnoses that included Abnormal posture, dementia, and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles).
Review of Resident 3's clinical record revealed an incident note on July 31, 2023, at 8:57 PM, that stated, Description of Incident/Accident: Notified by [Nurse Aide] of bruise to R[ight] outer elbow. Resident Comments/Cognitive Status: [Resident 8] states that she 'woke up with it one morning' and 'didn't know where it came from' Evaluation/Injury including measurements of wounds if applicable: Bruise observed on R[ight] outer elbow measuring 3cm X 2cm. No complaints of of pain.
Further review of the incident note on July 31, 2023, at 8:57 PM, revealed the section of the note was left blank for Immediate intervention for prevention, Care/Treatment Provided.
During email correspondence with the NHA on September 12, 2023, at 12:07 PM, the surveyor inquired about an investigation related to Resident 8's bruise discovered on July 31, 2023.
Review of Resident 8's care plan revealed no new interventions were added related to the discovered bruise after July 31, 2023.
Interview with Employee 1 on September 13, 2023, at 10:27 AM, revealed she does not have any information to provide that an investigation was conducted, and she would expect a thorough investigation to be completed per the facility policy.
During an interview with the NHA on September 14, 2023, at 11:03 AM, the surveyor revealed the concern with the facility's failure to follow established procedures for investigation and protection of residents related in response to potential abuse. The NHA revealed she would expect a thorough investigation to be completed per the facility policy.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders for t...
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Based on clinical record review and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders for three of 12 resident's reviewed (Resident 21, 28, and 34).
Findings Include:
Review of Resident 21's clinical record revealed diagnoses that included hypertension (high blood pressure), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), and dysphagia (difficulty swallowing).
Review of Resident 21's physician orders revealed an order for: Amlodipine Besylate Oral Tablet 5 MG (milligrams- unit of measure), Give 5 mg by mouth two times a day related to Hypertension, Call MD (doctor) if B/P (blood pressure) >160 and if HR (heart rate) <50, with a start date of July 26, 2023.
Review of Resident 21's MAR (Medication Administration Record- documentation for medication/treatment administered or monitored), revealed Resident 21's blood pressure measure was >160 on August 6, 7, 16, and 20, 2023; and September 1, 5, 6, and 13, 2023.
Review of Resident 21's medical record revealed no documentation to indicate the doctor was notified of Resident 21's blood pressure measures being >160 on August 6, 7, 16, and 20, 2023, and September 1, 5, 6, and 13, 2023.
Interview with the Director of Nursing (DON) on September 14, 2023, at 11:03 AM, revealed she could not find any information to indicate the doctor was notified of Resident 21's blood pressure measures being >160 on August 6, 7, 16, and 20, 2023; and September 1, 5, 6, and 13, 2023, and she would expect physician orders to be followed.
Review of Resident 28's clinical record revealed diagnoses that included Multiple Sclerosis (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and hypertension.
Review of Resident 28's clinical record revealed a documented, titled Physician Communication- Fax Orders/Telephone Orders, further review of the document revealed, Physician Orders: Consult with Neurologist to see if myzent (a medication for multiple sclerosis) is contributing to an increase in blood pressure, dated June 17, 2023, and signed by Employee 9 (Medical Director).
Further review of Resident 28's clinical record revealed no documentation to indicate Resident 28 has seen a neurologist or that communication has been made with a neurologist related to the physician order after June 17, 2023.
Interview with Employee 1 (Clinical Excellence Nurse) on September 14, 2023, at 12:12 PM, revealed she was unable to find any documentation to indicate Resident 28 has seen a neurologist since June 17, 2023, or that communication has been made with a neurologist related to the physician order.
During an interview with the Nursing Home Administrator on September 14, 2023, at 12:15 PM, the surveyor revealed the concern with Resident 28's physician order not being followed. No further information was provided.
Review of Resident 34's clinical record on September 11, 2023, at approximately 1:00 PM, revealed diagnoses that included type 2 diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should) with hyperglycemia (when a person's blood sugar elevates to dangerous levels) and Major Depressive Disorder.
Review of Resident 34's physician orders revealed an order for skin inspection weekly as per skin integrity program on bath days, Tuesday daytime in the morning, and to document if skin impairment noted or not.
Review of Resident 34's MAR revealed Employee 12 (Licensed Practical Nurse) documented no skin impairment was present on Tuesday September 5, 2023, at 7:30 AM, and Tuesday September 12, 2023, at 7:30 AM.
Review of Resident 34's clinical record on September 12, 2023, at approximately 10:00 AM, revealed a document, titled Physician Communication - Fax Orders/Telephone Orders. Further review of the document revealed it contained, Problem: Redness/Excoriation vaginal area. Nystatin cream? dated September 6, 2023, at 11:45 PM, and signed by Employee 13 (Registered Nurse). It was it was observed that below the Problem area, the document contained a box for the physicians' response.
Review of the physician response revealed an order for a new order of Diflucan (antifungal medication) 100 milligrams by mouth twice a day for two days, dated and signed by Employee 9 (attending physician) on September 7, 2023.
Further review of Resident 34's clinical record revealed no documentation to indicate an initial assessment had been completed to record Resident 34's skin impairment.
During a staff interview with Corporate Clinical Excellence Nurse on September 14, 2023, at 11:05 AM, it was revealed that the facility could not provide a documented assessment of Resident 34's redness and excoriation of the vaginal area. During the staff interview, Corporate Clinical Excellence Nurse revealed it was the facility's expectation that an assessment of Resident 34's rash would have been conducted and documented.
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of menu extension forms, it was determined that the facility failed to provi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of menu extension forms, it was determined that the facility failed to provide food at appropriate portion sizes to meet the nutritional needs of residents for one of one meal observed (lunch meal, September 12, 2023).
Findings include:
Review of the menu diet extension sheet (menu items based on individual diets) for September, 12, 2023, lunch meal, revealed all diets should either be served a 4 ounce (unit of measure) portion of succotash or cream corn as the vegetable.
Observation of lunch service on the [NAME] unit on September 12, 2023, at 12:37 PM, revealed Employee 5 used a plain plastic serving utensil to serve both the succotash and cream corn.
During an interview with Employee 5 on September 12, 2023, at 12:39 PM, she revealed she is not sure how to tell what size portion the serving spoons were that she used to serve the succotash and cream corn.
Observation of lunch service on the [NAME] unit on September 12, 2023, at 12:48 PM, revealed Employee 6 used a 3 oz scoop to serve the succotash vegetable.
Interview with Employee 7 (Dietary Supervisor) on September 12, 2023, at 12:50 PM, revealed she would expect food to be served with the proper utensils for measured portions, and she plans to do education with the dietary staff.
Interview with the Nursing Home Administrator on September 13, 2023, at 10:07 AM, revealed it is the facility's expectation that food is served at appropriate portion sizes specified by the menu extension sheets.
Pa code 211.6(a)(b) - Dietary Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on resident and staff interviews, completion of a meal test tray, and review of select facility documentation, it was determined that the facility failed to provide food at an appetizing tempera...
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Based on resident and staff interviews, completion of a meal test tray, and review of select facility documentation, it was determined that the facility failed to provide food at an appetizing temperature at one of one meals (lunch meal, September 13, 2023).
Findings include:
Review of facility document, titled Test Tray Assessment last revised February, 2012, revealed that hot foods should be served at or above 130 degrees Fahrenheit (F - a unit of measure).
During an interview with Resident 4 on September 13, 2023, at 11:04 AM, she revealed her food is often served cold.
Review of June 2023 Resident Council Minutes (documentation of topics discussed during a monthly meeting), revealed concerns with food temperatures being too hot or too cold.
A Test Tray was completed on September 13, 2023, at 12:32 PM, utilizing a lunch tray served in Arlington unit dining area after all meals were served to resident's on the unit. Test Tray included: baked cod, carrots, scalloped potatoes, ice cream, hot tea, and milk. Temperatures taken by Employee 3 (Registered Dietitian) revealed the carrots were 122 degrees F and scalloped potatoes were 121 degrees F.
Interview with the Nursing Home Administrator on September 14, 2023, at 9:49 AM, revealed hot foods should be served at a temperature greater than 130 degrees Fahrenheit, as stated in the facility test tray documentation.
28 Pa. Code 211.6 (d) Dietary services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for four of 15 residents reviewed (Resident 7, 21, 34, and 41)
Findings Include:
Review of Resident 7's clinical record on September 11, 2023, at approximately 1:00 PM, revealed diagnoses that included stage 4 chronic kidney disease (severe decrease in the kidneys ability to filter toxins from the blood) and diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment).
Review of Resident 7's Minimum Data Set (MDS - Assessment tool utilized to identify a residents' physical, mental and psychosocial needs), including an admission MDS with an Assessment Reference Date (ARD) of February 7, 2023; a Significant Change MDS with an ARD of April 10, 2023; a Quarterly MDS from May 9, 2023; and a Quarterly MDS from August 9, 2023, revealed that Section N - Medications, subsection N350 was coded to reflect that Resident 7 was receiving insulin injections during the assessment look-back period.
Review of Resident 7's medications orders, including discontinued medications, since Resident 7's admission on [DATE], revealed that at no time was Resident 7 receiving insulin injections.
During a staff interview on September 14, 2023, at approximately 11:20 AM, Corporate Quality Excellence Nurse confirmed that Resident 7 had not received insulin and that Resident 7's MDS assessments were coded incorrectly in regard to Section N350.
Review of Resident 21's clinical record revealed diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dysphagia (difficulty swallowing), and hypertension (high blood pressure)
Review of Resident 21's clinical record revealed a provider note dated June 7, 2023, that stated, Diagnostic Statement: Dementia in other diseases classified elsewhere, severe, with psychotic disturbance (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) .Dementia With Complications.
Further review of Resident 21's clinical record revealed a provider note dated June 23, 2023, that stated, Diagnostic Statement: Dementia in other diseases classified elsewhere, severe, with psychotic disturbance .Dementia With Complications.
Review of Resident 21's Significant Change Minimum Data Set with ARD of July 3, 2023, revealed, Section I: Active Diagnoses, subsection I4800. Non-Alzheimer's Dementia, was not assessed to indicate that Resident 41 had a diagnosis of dementia.
Interview with Employee 1 (Clinical Excellence Nurse) on September 13, 2023, at 2:07 PM, revealed Resident 21's diagnosis of dementia was missed by Employee 2 (Registered Nurse Assessment Coordinator), and the assessment should have been coded to indicate Resident 21 has a diagnosis of dementia.
Interview with the Nursing Home Administrator (NHA) on September 14, 2023, at 12:12 PM, revealed she would expect the Resident assessment to be coded accurately.
Review of Resident 34's clinical record on September 11, 2023, at approximately 1:00 PM, revealed diagnoses including diabetes mellitus type II with hyperglycemia (when a person's blood sugar elevates to dangerous levels) and Major Depressive Disorder (ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).
Review of Resident 34's Quarterly MDS with an Assessment Reference Date of June 27, 2023, reveled that Section K - Swallowing/Nutritional Status, subsection K0300 was coded, No or unknown, for Weight loss of 5% or more in the last month or loss of 10% or more in last 6 months.
Review of Resident 34's clinical record revealed on December 6, 2022, Resident 34 weighed 191.6 pounds. On June 16, 2023, within the Assessment Reference Date of Resident 34's Quarterly MDS, Resident 34 weighed 168.4 pounds. This weight change indicated a 12.11 % loss.
During an interview with Corporate Clinical Excellence Nurse, in the presence of the NHA, on September 13, 2023, at 2:15 PM, revealed it was the facility's expection that the Resident 34's MDS assessment would be coded correctly.
Review of Resident 41's clinical record revealed diagnoses that included cerebral infarction (stroke - damage to the brain from interruption of its blood supply), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and hypertension.
Review of Resident 41's clinical record revealed a picture of Resident 41 wearing glasses.
Review of Resident 41's clinical record revealed an inventory sheet upon admission on [DATE], noting Resident 41 came with four pairs of glasses.
Review of Resident 41's 5 Day MDS with ARD of July 17, 2023, revealed under Section B - Hearing, Speech, and Vision, subsection B. 1000 Vision, Resident 41 was coded as Impaired, and subsection B. 1200 Corrective lenses Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision, Resident 41 was coded no to indicate she does not wear corrective lenses.
Interview with Employee 1 on September 14, 2023, at 12:10 PM, revealed Resident 41 wore glasses and it should have been coded on her assessment.
Interview with the NHA on September 14, 2023, at 12:12 PM, revealed she would expect the Resident assessment to be coded accurately.
28 Pa code 211.5(f) Clinical records
28 Pa code 211.12(d)(1)(3) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure care and services were provided to assess and maintain acceptable nutritional...
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Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure care and services were provided to assess and maintain acceptable nutritional status for two of five residents reviewed for nutrition (residents 27 and 34).
Findings include:
Review of facility policy, titled Weight Record Monitoring, last reviewed May 2023, revealed it stated, The physician and resident's responsible party are notified by the RD/designee of significant weight change (gain or loss) and of the IDT [interdisciplinary team] recommendations that would require further intervention/securing of new orders from the physician for the resident.
Review of Resident 27's clinical record on September 12, 2023, at approximately 10:15 AM, revealed diagnoses that included hypertension (elevated/high blood pressure) and cerebella ataxia (disorder that results in poor muscle control which can affect speech, swallowing, eye movement, and extremity movement).
Review of Resident 27's interdisciplinary progress notes revealed that on June 27, 2023, at 1:18 PM, Employee 3 (Registered Dietician) documented, .resident with current weight of 157lb [pounds], loss of 3.9lb in 30 days with a net significant loss of 26lb in 180 days (14.2%). Weight did stabilize from late April to May 2023, although trend now continues in June 2023. Resident continues on[sic] weekly weights to monitor, requested by 6/22/23 and by 6/29/23. Weight decline noted, despite resident consuming 76-100% of all meals .Recommend trailing additional entrée portion with meals, and offer additional (diet texture appropriate snack), between meals (AM, PM, HS). Consider geri-psych review for mood & review appropriateness of current medication. Will continue to follow weight trends and overall nutritional status.
Review of a progress note documented on July 14, 2023, at 9:14 AM, by Employee 4 (Registered Dietician) revealed it stated, Net [weight] loss of 22 [pounds in] 180 days; 12%, significant [weight loss]. Intended increase of 4 [pounds] noted over past few weeks [related to] dietary interventions added due to weight loss .Weekly weights monitored .
Review of Resident physician orders on September 12, 2023, at approximately 10:30 AM, revealed no order for Resident 27 to receive weekly weights.
Review of Resident 27's comprehensive plan of care revealed that the care plan with the focus of: [Resident 27 has] a potential nutritional risk .[History] of weight loss & skin breakdown, included an intervention of, Obtain [Resident 27's] weight per weight standard. The intervention of weekly weights per Employee 3's progress note entered on June 27, 2023, was not included.
Review of Resident 27's documented weights revealed that Resident 27 was not weighed during one week in June, 2023; four weeks during July, 2023; one week in August, 2023; and one week in September 2023.
As of September 14, 2023, at 9:00 AM, Resident 27 did not have a documented weight since September 1, 2023.
Review of Resident 27's clinical record on September 14, 2023, at approximately 11:30 AM, revealed a physician's order for weekly weights that was entered at 10:43 AM on September 14, 2023.
During a staff interview on September 14, 2023, at approximately 12:00 PM, Corporate Clinical Excellence Nurse confirmed that Resident 27 did not have weekly weights ordered. During the interview, Corporate Clinical Excellence Nurse confirmed it was the facility's expectation that weekly weights should have been conducted on Resident 27 per the progress notes by Employee 3 and Employee 4 on June 27, 2023, and July 14, 2023, respectively.
Review of Resident 34's clinical record on September 11, 2023, at approximately 1:00 PM, revealed diagnoses that included type 2 diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should) with hyperglycemia (when a person's blood sugar elevate to dangerous levels) and Major Depressive Disorder (ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).
Review of Resident 34's clinical record, on September 12, 2023, revealed three significant weight losses (as defined as 5% or more weight loss in one month and/or 10% or more in six months) since admission to the facility.
Review of Resident 34's documented weights revealed that on October 12, 2022, facility staff documented that Resident 34 was admitted weighing 203.3 pounds. Approximately six months later on April 5, 2023, Resident 34's documented weight was 164.7 pounds, which indicated an 18.99% loss.
Review of Resident 34's interdisciplinary progress notes revealed that on April 3, 2023, Employee 3 documented a Nutrition note, which stated, .current weight 166[pounds], stable in 30 days with net significant loss of 37[pounds] in 180 days (18.2). Loss mostly [related to] improved fluid status after admission to this facility. Resident did have notable decline in oral intake from 3/9/23 to 3/29/23, which was supplemented with Glucerna 8oz daily [for] 30 days .No new recommendations at this time.
Review of the clinical record revealed no documentation or evidence that Employee 3 notified the attending physician that Resident 34 had a significant weight loss during the prior 180 days.
Review of weight documentation revealed that on August 10, 2023, Resident 34's documented weight was 176.8 pounds.
On September 8, 2023, Resident 34's document weight was 165.4 pounds, which was a 6.45% loss within a 30 day period.
Review of Resident 34's interdisciplinary progress notes on September 14, 2023, at approximately 12:15 PM, revealed no dietary note by a facility Registered Dietician regarding the significant weight loss of more than 5% between August 10, 2023, and September 8, 2023.
Review of Resident 34's clinical record revealed no documentation that the physician was made aware of the significant weight losses identified as a result of weight assessments documented on April 5, 2023; June 16, 2023; and September 8, 2023.
During a staff interview on September 14, 2023, at approximately 11:08 AM, Corporate Clinical Excellence Nurse was unable to provide documentation that the attending physician was notified of Resident 34's significant weight changes identified above, nor was Corporate Clinical Excellence Nurse able to provide documentation that the attending physician acknowledged and/or addressed the identified weight loss.
28 Pa code 211.10(a)(d) Resident care policies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility 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 and two of three nourishment areas.
Findings include:
Review of facility policy, titled 3.4 Storing Food and Equipment, last revised March, 2020, revealed, Ensure all food items are labeled .Each label must contain the following information: Use-by date, date the product was prepared or opened .Generally, food should be discarded or used by the use-by date. The use-by date is the last date the manufacturer recommends use of the food and also may be referred to as the expiration date .cover, label and date all leftovers .keep all storage areas clean and dry.
Observation in the main kitchen on September 11, 2023, at 9:28 AM, revealed a shelf with a container of cayenne pepper with a use-by date of August 19, 2023, and the shelf was heavily soiled.
Further observation in the main kitchen on September 11, 2023, at 9:30 AM, revealed a bag of raisin bread without a date.
Observation of the dry storage area on September 11, 2023, at 9:36 AM, revealed: one bag of granola labeled use by September 10, 2023; and two bags of potato chips labeled use by August 29, 2023.
Observation of the ice machine in the main kitchen on September 11, 2023, at 9:43 AM, revealed the lid was dirty. When the surveyor looked inside the ice machine, the top of the inside of the ice machine was dirty with a black substance.
Observation of one reach-in refrigerator unit in the main kitchen on September 11, 2023, at 9:45 AM, revealed a pan containing four saucers of diced peaches not labeled, dated, or covered.
Observation of a reach-in freezer unit in the main kitchen on September 11, 2023, at 9:48 AM, revealed: one container of coffee cake with a use by date of July 1, 2023; one bag of meatloaf with a use by date of August 15, 2023; and one bag of meatballs with a use by date of August 15, 2023.
Observation of a second reach-in refrigerator unit in the main kitchen on September 11, 2023, at 9:52 AM, revealed: two containers of beef base open without an open or a use by date; one container of pork base open without an open or use by date; one container of heavy whipping cream open without a date; and one container of horseradish labeled use by August 26, 2023.
Observation of the walk-in refrigerator on September 11, 2023, at 9:56 AM, revealed: one bag of lettuce without a label or date; one bag of cilantro labeled use by September 6, 2023; and one bag of shredded parmesan cheese labeled use-by 8-18.
Observation in walk-in freezer unit on September 11, 2023, at 10:03 AM, revealed: one bag of blue cheese crumbles with a use by date of March 8, 2023; one container of green beans open without a use by date; and one bag of raisin bread without a date.
Further observation of the walk-in freezer unit on September 11, 2023, at 10:05 AM, revealed food storage was stacked above the sprinkler head in the freezer.
Observation during initial tour of the [NAME] pantry area refrigerator on September 11, 2023, at 10:12 AM, revealed: one container of chocolate syrup with a use by date of August 25, 2023, and one open can of Pepsi not dated or covered.
Observation of the [NAME] pantry area dry storage on September 11, 2023, at 10:16 AM, revealed: one open container of pancake mix without a use by date; one bag of sugar packets without a date; one container of mustard open without a date; and one individual container of brown sugar not labeled or dated.
Further observation of the [NAME] pantry area on September 11, 2023, at 10:16 AM, revealed the microwave was dirty with a brown substance on the inside, and there were no paper towels in the holder for the hand sink.
Interview with Employee 7 (Dietary Supervisor) on September 11, 2023, at 10:20 AM, revealed she would expect the microwave to be cleaned after each meal service, paper towels to be stocked for handwashing, the ice machine and shelves in the kitchen to be clean, food not to be stocked above 18 inches from the ceiling, and food items to be labeled and dated per facility policy and discarded once past the use by date.
Observation during initial tour of the Arlington pantry area on September 11, 2023, at 10:29 AM, revealed: one package of lemonade mix not dated; one bag of toasted o's cereal labeled use by August 22, 2023; two bags of potato chips labeled use by August 29, 2023; one container of oatmeal pies without an open or use by date; one container of fig bars without an open or use by date; and one container of powdered sugar on the counter not labeled or dated.
Observation of the Arlington pantry area refrigerator on September 11, 2023, at 10:34 AM, revealed one tomato in a bin not dated.
Observation of the Arlington pantry area freezer on September 11, 2023, at 10:36 AM, revealed: two bags of English muffins not dated, and one container of sherbet not dated.
Interview with the Nursing Home Administrator on September 13, 2023, at 10:07 AM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored, cleaned, and utilized in accordance with professional standards.
28 Pa. Code 211.6(f) Dietary services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to consistently implement and maintain infection control practices, including ...
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Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to consistently implement and maintain infection control practices, including PPE (Personal Protective Equipment) use, to prevent spread of the tuberculosis infection for one of 15 residents reviewed (Resident 41).
Findings Include:
Review of Facility Policy, titled Tuberculosis Screening, last reviewed August 23, 2023, revealed, This center shall screen all residents for active tuberculosis (TB) .Nursing team members will place an appropriate mask over the mouth and nose of any resident having, or suspected of having active TB (whether based on X-ray results, clinical findings, or both), and will arrange for prompt transfer to an acute care hospital.
Review of Resident 41's clinical record revealed documentation to indicate the Resident received a step-1 TB PPD test upon admission to the facility on July 13, 2023.
Review of Resident 41's clinical record revealed an alert note on July 15, 2023, at 2:55 PM, that stated, Resident noted to have a large red area with a 5mm (millimeter- unit of measure) induration to left forearm at the site of her PPD test. On call physician notified and ordered chest x-ray, RP (responsible party) notified. Resident denies any past positive ppd tests or knowledge of TB exposure. She is asymptomatic at this time.
Review of Resident 41's clinical record revealed a nursing note on July 15, 2023, at 9:27 PM, that stated, Call to [Employee 8 (Medical Doctor)], regarding chest x-ray result of chronic tuberculosis calcification, she is in agreement that future PPD's will have positive result, verbal order taken to discontinue 2nd step. DON (Director of Nursing) updated.
Review of Resident 41's clinical record revealed a lab note on July 16, 2023, at 2:20 PM, that stated, X-Ray results reviewed with [Employee 8], New order to collect Quantiferon lab (TB blood test). RP updated.
Review of Resident 41's clinical record revealed a nursing note on July 16, 2023, at 11:48 PM, that stated, Blood draw from left antecubital (A/C- arm), well tolerated. Blood taken to [Hospital] lab for TB Quantiferon.
Review of Resident 41's clinical record revealed a nursing note on July 17, 2023, at 10:30 AM, that stated, Quantiferon Gold redrawn related to lab call for need of more blood. Blood drawn from the left A/C space on first attempt. Resident tolerated the procedure without difficulty. Gauze and band-aid applied after blood stopped. Blood sent to the lab on ice to be resulted.
Review of Resident 41's clinical record revealed a change of condition note on July 20, 2023, at 7:07 AM, that stated, Resident's Quantiferon Gold results- Positive. DON called Medical Director and reported results. The trajectory (time frame) of the pathway from 7/13 admission PPD to Chest X-ray [48 hrs after PPD read] to positive Quantiferon Gold discussed. Medical Director notified ER (Emergency Room) physician and discussed resident's condition and testing results. DON notified the DOH (Department of Health) and received the information of required testing to confirm if TB is Active or Latent Phase. Resident with no cough present. Resident asymptomatic. Resident requiring a hospital transfer for further testing . Medical Director instructed DON to send resident to ED (Emergency Department) .DON instructed to send resident to ED and to instruct EMS to wear gown, gloves, N95 mask, and face shield. DON instructed to implement airborne precautions with staff. Resident wearing PPE when transferred out of facility. DON sent Chest X-ray and Quantiferon TB results to the DOH.
Further Review of Resident 41's clinical record revealed no indication the Resident was placed on any precautions or PPE was placed in use, per facility policy, prior to July 20, 2023, at 7:07 AM.
Interview with Employee 1 (Clinical Excellence Nurse) on September 14, 2023, at 12:09 PM, revealed she could not find any documentation to indicate Resident 41 had any transmission-based precautions in place for TB prior to July 20, 2023.
During an interview with the Nursing Home Administrator on September 14, 2023, at 12:10 PM, the surveyor revealed the concern with no indication Resident 41 had any transmission-based precautions or PPE in place for TB prior to July 20, 2023. No further information was provided.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on employee education documentation review, facility documentation review, and staff interview, it was determined that the facility failed to ensure two of five nurse aides reviewed received at ...
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Based on employee education documentation review, facility documentation review, and staff interview, it was determined that the facility failed to ensure two of five nurse aides reviewed received at least 12 hours of education per year, which included dementia management and resident abuse prevention training (Employees 10 and 11).
Findings include:
Review of the facility's Job Description for the job titled Nursing Assistant (Nurse Aide), last revised November 8, 2017, revealed, General Responsibilities, included, [The employee] [c]ompletes educational requirements as mandated by state and federal agencies to maintain competencies.
Review of facility documentation submitted by the facility on September 11, 2023, revealed that the Employee Education and Development trainings included, but not limited to, courses, titled Preventing, recognizing, and Reporting Abuse and dementia training, titled Teepa Snow: Dementia 101.
Review of Facility documentation revealed that Employee 10 was hired for a Nurse Aide position on November 13, 2019.
Review of Employee 10's facility education transcript revealed that, during the calendar year of 2022, Employee 10 only received 8.00 hours of annual training.
Review of Employee 10's facility education for the 12 month period between September 12, 2022, and September 12, 2023, revealed that, during the 12 month period, Employee 10 completed only 2.00 hours of the facility's education.
Further review of Employee 10's facility education revealed that Employee 10 had not completed the facility's training in Preventing, Recognizing, and Reporting Abuse in the years 2021, 2022, and up until review on September 13, 2023.
Facility Employee 10 also did not receive the facility's specific training on residents with dementia in the years 2021, 2022, and up until the review on September 13, 2023.
During a staff interview on September 14, 2023, at approximately 12:00 PM, Nursing Home Administrator (NHA) and Corporate Clinical Excellence Nurse confirmed that Employee 10 did not receive 12 hours of annual education, and did not receive annual training on the facility's abuse prohibition policies and residents with dementia.
Review of Facility documentation revealed that Employee 11 was hired for a Nurse Aide position on October 2, 2019.
Review of Employee 11's facility education transcript revealed that, during the calendar year of 2022, Employee 11 only received 7.75 hours of annual training.
Review of Employee 11's facility education for the 12 month period between September 12, 2022, and September 12, 2023, revealed that, during the 12 month period, Employee 11 completed only 9.00 hours of the facility's education.
Further review of Employee 11's facility education revealed that it had been more than 12 months since Employee 11 completed the facility's training in Preventing, Recognizing, and Reporting Abuse. Review of Employee 11's education transcript revealed the education was last completed on July 2, 2022.
During a staff interview on September 14, 2023, at approximately 12:00 PM, the NHA and Corporate Clinical Excellence Nurse confirmed that Employee 11 did not receive 12 hours of annual education and did not receive annual training on the facility's abuse prohibition policies at least once every 12 months.
28 Pa code 201.14(a) Responsibility of the licensee
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Concerns
- • 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Spiritrust Lutheran The Village At Luther Ridge's CMS Rating?
CMS assigns SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Spiritrust Lutheran The Village At Luther Ridge Staffed?
CMS rates SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes.
What Have Inspectors Found at Spiritrust Lutheran The Village At Luther Ridge?
State health inspectors documented 24 deficiencies at SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE during 2023 to 2025. These included: 24 with potential for harm.
Who Owns and Operates Spiritrust Lutheran The Village At Luther Ridge?
SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 40 certified beds and approximately 33 residents (about 82% occupancy), it is a smaller facility located in CHAMBERSBURG, Pennsylvania.
How Does Spiritrust Lutheran The Village At Luther Ridge Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE's overall rating (3 stars) matches the state average and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Spiritrust Lutheran The Village At Luther Ridge?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Spiritrust Lutheran The Village At Luther Ridge Safe?
Based on CMS inspection data, SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Spiritrust Lutheran The Village At Luther Ridge Stick Around?
SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Spiritrust Lutheran The Village At Luther Ridge Ever Fined?
SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Spiritrust Lutheran The Village At Luther Ridge on Any Federal Watch List?
SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.