Health inspection·August 21, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders to obtain therapy services for one of three sampled residents who were referred to therapy. (Resident 1) Residents Affected - Few Findings include: Clinical record review revealed that Resident 1 had diagnoses that included depression, pain, dementia, osteoarthritis, lack of coordination, and difficulty walking. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident required extensive assistance from staff for activities of daily living. On April 14, 2023, staff documented that the resident had decreased strength and endurance and that the resident's family had requested physical therapy for ambulation. A physician's order dated April 14, 2023, referred the resident for therapy services per the resident's family's request. There was no evidence that the resident was evaluated for therapy services, per the physician's order. In an interview on August 21, 2023, at 1:41 p.m., the Assistant Director of Nursing confirmed there was no evidence that the resident was evaluated for therapy services, per the physician's order. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395117 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)