Health inspection·May 29, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed was free from physical restraints (Resident 1). Residents Affected - Few Findings include: Review of facility policy, Restraint Policy, undated, revealed: restraint use in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident or other residents and under the following conditions: 1) as a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful; 2) with a physician order; 3) with the consent of the resident or legal representative; 4) when the benefits of the restraint outweigh the identified risks. Review of facility orientation packet given to outside nursing staff and nursing students revealed: This is a restraint free facility. Review of nurse aide Employee E5's orientation packet revealed the employee signed acknowledgement of receipt and understanding of the orientation materials on October 7, 2023. Review of Resident 1's clinical record revealed the resident was admitted to the facility April 23, 2024, with diagnoses including Parkinson's (chronic and progressive movement disorder that causes tremors, stiffness or slowing of movement), severe dementia (general decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control) with psychotic disturbance, psychotic disorder with delusions, hallucinations, disorientation, unsteadiness on feet, unspecified abnormalities of gait and mobility, and cognitive communication deficit. Review of Resident 1's admission MDS (minimum data set - periodic assessment of resident care needs) dated April 28, 2024, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 01, indicating severe cognitive impairment. Review of Resident 1's clinical record failed to reveal orders for any type of restraint. Interview with the recreation manager, Employee E3, on May 29, 2024, at approximately 9:50 a.m. revealed that the employee was made aware by the activity aide, Employee E4, on May 13, 2024, at 4:15 p.m., that Resident 1 had a gait belt (a device put on someone who has mobility issues to aid caregivers in moving them) wrapped around their waist and the wheelchair in the dining room. Employee E3 (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 05/29/2024 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)