Inspection·February 24, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to ensure a thorough investigation was completed for injuries of unknown origin for 2 of 18 residents reviewed (Resident 15 and Resident 28). Residents Affected - Few Findings include: Review of facility policy and procedure titled Accident, Incident and Death Reporting/Investigation, revised 2019, revealed Any injury should be classified as an 'injury of unknown origin' when the following conditions are met: a) the origin of the injury was not observed by any person or the origin of the injury could not be explained by the resident; b) the injury is suspicious because of the extent of the injury, or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma such as, but not limited to breast or groin area), or the number of injuries observed at one particular point in time (such as multiple bruises in a pattern resembling finger marks), or the incidence of the injuries over time and c) there is no reasonable determination as to how the injury occurred (e.g. a confused resident that self-propels a wheelchair and is known to occasionally bump into doorways, etc., and gets a large bruise on the back of the hand). Further review of this policy and procedure revealed In order to determine probable cause for injuries of unknown origin - statements shall be obtained from team members who were assigned to the resident within 24 hours (3 shifts) prior to becoming aware of the injury. Review of Resident 15's clinical progress notes dated February 14, 2023, revealed While CNA was providing am [morning] care, CNA noted multiple green/yellow bruises on left upper arm. No c/o [complaints of] pain was noted this shift. Resident was unable to explain how areas happened. POA was notified on bruises. Fax was prepared to update MD on bruises. Review of facility documentation revealed only one staff member's statement was obtained regarding Resident 15's bruises. Review of Resident 28's clinical progress notes dated February 16, 2023, revealed that the nurse aides, alerted the nurse that when they took the residents sock off they noticed a bruise at the residents right ankle. Slight swelling noted. The bruise is 10 cm [centimeter] in length and wraps around to the front of the lower rt leg. POA notified of bruise, MD [Medical Doctor] order for an x-ray. Review of facility documentation revealed one staff members statement was obtained regarding Resident 28's bruise. One staff member was interviewed regarding the resident's daily behaviors. Interview with Nursing Home Administrator and Director of Nursing on February 24, 2023, at 11:00 (continued on next page) 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: 395406 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 395406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Acres Manor 400 Saint Luke Dr Lititz, PA 17543 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)