Health inspection·December 14, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **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 a resident's code status for one out of 24 residents reviewed (Resident 71). Findings include: Review of the clinical record revealed Resident 71 was admitted to the facility on [DATE]. Review of Resident 71's clinical record revealed a POLST (Pennsylvania -Orders for Life Sustaining Treatment), signed on February 7, 2023, indicating the resident wanted life sustaining code status to be considered, Do Not Resuscitate (DNR). Review of the physician orders revealed the DNR was not current. Interview with the Social Service Director, Employee E3 December 7, 2023 at 10:30 a.m., confirmed the DNR order was not listed on the residents physician orders as Resident 71 intended as stated on the POLST form. The facility failed to ensure the resident's right to formulate an advance directive for Resident 71. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 201.29(j) Resident rights. Page 1 of 3 395406 395406 12/14/2023 Luther Acres Manor 400 Saint Luke Dr Lititz, PA 17543

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on clinical records review and staff interview, it was determined that the facility failed to investigate an allegation of being rough during care for one of the 18 residents reviewed (Resident 8). Residents Affected - Few Findings include: Review of Resident 8's diagnosis list includes Traumatic Brain Injury (TBI), and Anxiety (intense, excessive and persistent worry and fear about everyday situations). Review of Resident 8's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated September 14, 2023, revealed resident had moderate impairment with cognition and required extensive assistance with personal hygiene and dressing. Review of Resident 28's nursing progress notes dated October 16, 2023, at 2:56 p.m., revealed Resident 8 told the aide assisting her/him that she/he was being too rough. Another aide came to assist the resident then pulled the second aide's hair and said, Was that soft and gentle? Interview was conducted with the Director of Nursing (DON) on December 14, 2023, at 10:00 a.m. The DON reported a second aide came to assist the first aide after the allegation of being rough was made by the resident. The incident was reported to the nurse who then documented the incident to the EMR (Electronic Medical Record). The DON confirmed that Resident 8's allegation of the first aide being rough during care was not investigated. The facility failed to investigate Resident 8's allegation of staff being rough during care was conducted. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services 28 Pa. Code 201.29(j) Resident rights. 395406 Page 2 of 3 395406 12/14/2023 Luther Acres Manor 400 Saint Luke Dr Lititz, PA 17543

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 Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to follow physician orders for the administration of insulin for one of two residents reviewed (Resident 64). Residents Affected - Few Findings include: Review of facility policy and procedure titled Insulin Administration, revised February 2015 revealed Check blood glucose per physician order or nursing protocol. Review of Resident 64's diagnosis list revealed diagnoses including Type 2 Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment). Review of Resident 64's physician orders revealed an order to check glucose with Libre 2 system three times per day before meals. Further review of Resident 64's physician orders revealed an order for Novolog Insulin, Inject 10 units twice daily morning and afternoon with meals. Hold for blood sugar less than 150 and to inject 5 units every evening with meals. Hold for blood sugar less than 150. Review of Resident 64's November 2023 Medication Administration Record (MAR) revealed on November 3, 2023, at 11:00 a.m. Resident 64 received Novolog Insulin for a blood sugar of 148; November 9, 2023 at 4:00 p.m. Resident 64 received Novolog Insulin for a blood sugar of 148; November 11, 2023 at 7:30 a.m. and 4:00 p.m. Resident 64 received Novolog Insulin for blood sugars of 111 and 115; November 14, 2023 at 4:00 p.m. Resident 64 received Novolog Insulin for a blood sugar of 124; November 16, 2023 at 11:00 a.m. Resident 64 received Novolog Insulin for a blood sugar of 134; November 17, 2023 at 7:30 a.m. and 11:00 a.m. Resident 64 received Novolog Insulin for blood sugars of 141 and 136; November 18, 2023 at 7:30 a.m., 11:00 a.m. and 4:00 p.m. Resident 64 received Novolog Insulin for blood sugars of 145, 138 and 145; and on November 23, 2023 at 11:00 a.m. Resident 64 received Novolog Insulin for a blood sugar of 90. Interview with the Director of Nursing on December 14, 2023, at 10:00 a.m. confirmed that Resident 64 received Novolog Insulin with blood sugars outside the parameters of Resident 64's physician orders. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services 395406 Page 3 of 3