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. Page 1 of 2 395117 395117 08/21/2023 Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment for pressure ulcers for one of three sampled residents with pressure ulcers. (Resident 3) Residents Affected - Few Findings include: Clinical record review revealed that Resident 3 had diagnoses that included anemia and weakness. Review of a wound evaluation dated August 15, 2023, revealed that Resident 3 had a stage three pressure ulcer to the left upper back. The treatment plan recommendation was for staff to apply hydrogel and gauze island once daily for 30 days. There was no evidence that staff entered the recommended treatment into the resident's clinical record or provided treatment to the pressure ulcer until August 21, 2023, six days after the evaluation. In an interview on August 21, 2023, at 3:42 p.m., the Assistant Director of Nursing confirmed staff should have entered the treatment into the resident's clinical record and there was no evidence that any wound treatment was provided to the resident's pressure ulcer prior to August 21, 2023. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395117 Page 2 of 2