Health inspection·November 15, 2023

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer and the reasons for transfer in writing for 12 of 14 sampled residents who were transferred to the hospital. (Residents 8, 20, 22, 49, 55, 70, 115, 117, 125, 128, 134, 171) Findings include: Review of the facility policy entitled, Discharge and Transfer, last reviewed January 25, 2023, revealed that the facility must notify the resident and resident representative in writing prior to a transfer or discharge in a language and manner they understand. Clinical record review revealed that Resident 8 was transferred and admitted to the hospital on [DATE], and October 10, 2023, after changes in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 20 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 22 was transferred and admitted to the hospital on [DATE], and October 5, 2023, after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 49 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 55 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Page 1 of 9 395117 395117 11/15/2023 Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Clinical record review revealed that Resident 70 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 115 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 117 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 125 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 128 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 134 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 171 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. In an interview on November 14, 2023, at 12:15 p.m., the Administrator confirmed that written transfer information, including the reasons for the move, was not provided to the residents and the residents' representatives. 395117 Page 2 of 9 395117 11/15/2023 Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562

F 0641 Ensure each resident receives an accurate assessment. 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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's status for one of 36 sampled residents. (Resident 157) Residents Affected - Few Findings include: Clinical record review revealed that Resident 157's MDS assessment dated [DATE], Section C (Brief Interview for Mental Status) was incomplete and Section H (Appliances) inaccurately indicated that the resident had an indwelling catheter. There was no documented evidence or physician's order to reflect that the resident had an indwelling catheter. In an interview on November 15, 2023, at 9:45 a.m., the Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS sections were not completed accurately during the assessment period to reflect the resident's current status. 395117 Page 3 of 9 395117 11/15/2023 Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of incident reports and staff interview, it was determined that the facility failed to provide adequate supervison and interventions in order to prevent falls for one of six sampled residents who were at risk for falls. (Resident 131) Findings include: Clinical record review revealed that Resident 131 had diagnoses that included dementia, anxiety, insomnia and a lack of coordination. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and experienced behaviors that occurred daily including pacing and rummaging. The assessment also indicated that the resident required supervision to walk in the corridor and on the unit and required limited assistance for transfers and that the resident had experienced two or more falls during the assessment period. A review of the care plan revealed that the resident was at risk for falling related to frequent falls, cognitive loss, a desire to ambulate frequently, wandering, a recent history of falls, attempts to self transfer and non-compliance with her transfer status. There was an intervention that she required an assist of one with the rolling walker for transfers. Review of incident reports revealed that on March 4, at 11:46 a.m, the resident had fallen and was found on the floor. On March 12, 2023, at 11:05 a.m., the resident was walking in the hallway without her rolling walker and she fell forward onto the floor. On March 17, 2023, at 8:03 p.m., the resident had fallen and was found on the floor. On April 15, 2023, at 12:00 p.m., the resident was found on the floor in the hallway without her walker and had a laceration to her upper eye. On the same day, the resident fell again at 6:55 p.m On May 26, 2023, at 6:30 p.m., the resident had fallen and had hit her head. On the same night at 8:44 p.m., the resident fell and again hit her head. On May 30, 2023, at 11:32 a.m., the resident was found on the floor in her room holding her head. On June 2, 2023, at 6:00 p.m., the resident was found on the floor in the hallway. The resident stated that I was running and I tripped and fell. On June 9, 2023, at 3:38 p.m., the resident was found on the floor in another resident's room. On July 5, 2023, at 4:00 p.m., the resident was observed running in the hallway without her walker and she fell. On July 26, 2023, at 2:36 p.m., the resident was found on the floor near the nursing station and appeared to have attempted to stand independently and fell. On July 31, 2023, at 12:00 p.m., the resident was again found on the floor near the nursing station. Review of incident reports from March 4, 2023, through July 31, 2023, revealed that the resident had experienced six falls on the day shift between 11:00 a.m., through 2:45 p.m., and eight falls on the evening shift between 3:00 p.m., through 8:44 p.m., for a total of 13 falls in five months. There was a lack of documentation to support that the facility provided adequate supervision to prevent 395117 Page 4 of 9 395117 11/15/2023 Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562

F 0689 multiple falls in the early afternoon into the early evening hours. Level of Harm - Minimal harm or potential for actual harm In an interview on November 5, 2023, at 11:10 a.m., the Administrator stated that there was no documented evidence that the facility implemented adequate interventions and/or supervision in order to prevent multiple falls. Residents Affected - Few 28 Pa. Code 211.12 (d)(1)(5) Nursing services. 395117 Page 5 of 9 395117 11/15/2023 Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the pharmacist's recommendations were acknowledged by the physician for one of 36 sampled residents. (Resident 20) Findings include: Clinical record review for Resident 20 revealed multiple recommendations from the consultant pharmacist on July 27, August 18, and September 28, 2023. These included recommendations regarding seizure medications and bowel stimulants. There was no documented evidence that Resident 20's physician acknowledged or acted upon the pharmacist's recommendations. In an interview on November 14, 2023, at 3 p.m., the Assistant Director of Nursing confirmed that there was no documented evidence that the physician acknowledged Resident 20's recommendations from the pharmacist. 28 Pa. Code 211.12(d)(5) Nursing services. 395117 Page 6 of 9 395117 11/15/2023 Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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 document the rationale for the continued use of as needed (PRN) anti-anxiety medications for three of five sampled residents. (Residents 128, 134, 168) Findings include: Clinical record review revealed that Resident 128 had diagnoses that included Alzheimer's disease, dementia, psychosis, anxiety and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and had taken an anti-anxiety medication three days of the assessment period. A review of the care plan revealed that the resident had increased behaviors. There was an intervention for the primary care physician to monitor drug use. On September 8, 2023, a physician ordered for staff to administer an anti-anxiety medication (Ativan) every four hours PRN for anxiety and/or behaviors. Review of the Medication Administration Records (MAR's) for September, October, and November 2023, revealed that staff had administered the PRN anti-anxiety medication 15 times in September, 13 times in October and two times in November and the physician's order was still current for the PRN medication. There was no documentation in the resident's clinical record to extend the PRN Ativan beyond the 14 days from the original order on September 8, 2023. Clinical record review revealed that Resident 134 had diagnoses that included anxiety disorder. Review of the MDS assessment dated [DATE], indicated that the resident had no memory impairment and had taken an anti-anxiety medication. A review of the care plan revealed that the resident had anxiety. There was an intervention for the primary care physician to monitor drug use. On October 14, 2023, a physician's order directed staff to administer an anti-anxiety medication (lorazepam) every 12 hours as needed for anxiety. Review of the MAR for October and November 2023, revealed that staff had administered the PRN anti-anxiety medication four times in October and three times in November and the physician's order was still current for the PRN medication. There was no documentation in the resident's clinical record to extend the PRN lorazepam beyond the 14 days from the original order on October 14, 2023. Clinical record review revealed that Resident 168 had diagnoses that included Alzheimer's disease, bi-polar disease, anxiety and schizoaffective disorder. The MDS assessment dated [DATE], indicated that the resident had some memory impairment and had taken an anti-anxiety medication during the assessment period. A review of the care plan revealed that the resident was at risk for a mood problem related to anxiety and bi-polar disease. There was an intervention for the primary care physician to monitor drug use. On October 31, 2023, a physician ordered for staff to administer an anti-anxiety medication (clonazepam) every 12 hours PRN for anxiety. Review of the MAR for October and November 2023, revealed that staff had administered the PRN anti-anxiety medication nine times and the physician's order was still current for the PRN medication. There was no documentation in the resident's clinical record to extend the PRN clonazepam beyond the 14 days from the original order on October 31, 2023. In an interview on November 15, 2023, at 10:00 a.m., the Assistant Director of Nursing confirmed there was no documented evidence that the aformentioned residents were reassessed after the 14 day period to determine the need to continue the medications. 395117 Page 7 of 9 395117 11/15/2023 Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562

F 0758 28 Pa. Code 211.12(d)(1)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395117 Page 8 of 9 395117 11/15/2023 Lutheran Home at Topton, The One South Home Avenue Topton, PA 19562

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of three sampled residents who utilized adaptive equipment for meals. (Resident 131) Residents Affected - Few Findings include: Clinical record review revealed that Resident 131 had diagnoses that included dementia, anxiety and a lack of coordination. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance from staff for eating. A review of the care plan revealed that the resident had a nutrition problem related to dementia and significance weight loss. There was an intervention for staff to provide adaptive equipment including Kennedy cups (spill proof drinking cups that included a lid and a straw), for all drinks. Review of an occupational therapy Discharge summary dated [DATE], revealed that upon discharge from therapy services, the resident was able to consistently drink by herself after staff placed the Kennedy cup into her hand. The recommendation was for the resident to maintain self hydration and the prognosis for that was good with consistent staff follow through. In addition, on November 14, 2023, a dietician noted that the resident continued to benefit from the use of adaptive equipment, including the use of Kennedy cups with lids and straws. On November 13, 2023, at 1:05 p.m., Resident 131 was observed seated in the dining room and she received her lunch: however, she was served her coffee in a regular mug without a lid or a straw. On November 14, 2023, at 9:33 a.m., she was again seated in the dining room, received her breakfast, and was served her coffee in a regular mug without a lid or a straw. On November 14, 2023, at 12:24 p.m., the resident was seated in the dining room and she had juice that was in a regular juice cup without a lid or a straw. In an interview on November 15, 2023, at 11:15 a.m., the Director of Nursing stated that the resident was to have her drinks served to her in a Kennedy cup as recommended by occupational therapy and the dietician. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. 395117 Page 9 of 9