Inspection visit

Health inspectionOctober 12, 2023

LUTHERAN HOME AT HOLLIDAYSBURGCMS #3954277 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 24 residents reviewed (Resident 3), resulting in the resident suffering mental anguish. Findings include: The facility's abuse policy, dated January 11, 2023, indicated that each resident had the right to be free from verbal, sexual, physical, and mental abuse; corporate punishment; misappropriation of property; and involuntary seclusion. Every resident in the facility was to be treated with consideration, respect, and full recognition of his/her dignity and individuality, and management and staff were jointly and individually responsible to ensure each resident was free from abuse, neglect, and misappropriation of property. A Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated September 13, 2023, indicated that the resident was alert and oriented, and required the extensive assistance of staff for daily care needs, including transfers and ambulation. Facility investigation documents, dated August 9, 2023, revealed that on August 8, 2023, at approximately 5:00 p.m. Licensed Practical Nurse 1 responded to Resident 3's call bell. Resident 3 asked Licensed Practical Nurse 1 to help her get her walker and get out of her recliner chair and into her wheelchair for dinner. At that time Licensed Practical Nurse 1 threw the resident's walker in front of her and told her to walk herself. Resident 3 then pushed herself out to the nurse's station where she talked to Licensed Practical Nurse 2 and told her what happened. Licensed Practical Nurse 2 immediately told the Director of Nursing what Resident 3 stated had happened. The Director of Nursing stated that she was too tired to stay and deal with it. Licensed Practical Nurse 2 notified the Nursing Home Administrator several hours later when she realized the Director of Nursing still had done nothing about the incident. The Nursing Home Administrator immediately came in to investigate. A witness statement, dated August 9, 2023, at 3:15 p.m., by Nurse Aide 3 indicated that he responded to Resident 3 waving at him from within her room. When he entered her room, she was upset. He noted that her wheelchair was approximately ten feet away from her and her walker was in front of her. Resident 3 told Nurse Aide 3 that Licensed Practical Nurse 1 moved her wheelchair, threw her walker in front of her, and told her to walk by herself. Nurse Aide 3 stated that he assisted the resident into her wheelchair, and Resident 3 proceeded to the nurse's station and she was still upset. A witness statement, dated August 9, 2023, by Staff Member 4 revealed that Resident 3 was (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 13 Event ID: 395427 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0600 Level of Harm - Actual harm Residents Affected - Few emotionally upset by the incident involving Licensed Practical Nurse 1 and that after the Director of Nursing was made aware of the incident, Licensed Practical Nurse 1 went to Resident 3 and stated, You may have just cost me my job. Resident 3 was emotionally distressed by this and verbalized she never intended for anyone to get fired. She stated that later in the evening, after the incident, Licensed Practical Nurse 1 came to give Resident 3 her bedtime medications but did not make any further comments to her at that time. Interview with the Nursing Home Administrator on October 12, 2023, at 11:23 a.m confirmed that Resident 3 was visibly upset regarding Licensed Practical Nurse 1's actions and words and that she remained upset the next day. He stated that the Director of Nursing should have immediately escorted Licensed Practical Nurse 1 out of the building and started an investigation, but she did not, and this allowed Licensed Practical Nurse 1 to have further contact with Resident 3 after the initial incident. He stated that Resident 3 was afraid to go back to her room and was tearful after this occurred. The Director of Nursing and Licensed Practical Nurse 1 were terminated. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(a)(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 2 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on a review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 24 residents reviewed (Residents 1, 26). Findings include: The facility's policy regarding care plan development, dated January 11, 2023, revealed that based on the Minimum Data Set assessments (mandated assessments of a resident's abilities and care needs) and any other related information, an individualized, person-centered care plan would be developed to address problems/needs, goals, and approaches/interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 12, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for daily care needs. Observations of Resident 1 on October 10, 2023, at 11:03 a.m. revealed that she had a machine that is able to remotely check her pacemaker at bedside. A nursing note for Resident 1, dated October 9, 2023, stated that the resident was due for her pacemaker check and the facility was to use the device at bedside. There was no documented evidence that a care plan was developed for a pacemaker for Resident 1. An interview with the Director of Nursing on October 11, 2023, at 9:50 a.m. confirmed that Resident 1 did not have a care plan for her pacemaker. A facility policy for elopement, dated January 11, 2023, indicated that all residents at risk, or those demonstrating attempts to leave the unit or building, will have a photograph taken and available for all team members to view and use. The interdisciplinary team provides goals and approaches to address the elopement risk. A quarterly MDS assessment for Resident 26, dated August 15, 2023, revealed that the resident was understood and able to understand others, required extensive assistance with daily care needs, and had diagnoses that included Alzheimer's disease. Review of an elopement risk assessment, dated August 7, 2023, indicated that Resident 26 had an elopement risk score of 22, indicating she was a high risk for elopement. A nurse's note for Resident 26, dated August 7, 2023, at 9:50 a.m., indicated that an elopement risk assessment was completed and identified that resident as a high risk for elopement. The resident was to be placed on the elopement list. Review of Resident 26's current care plan revealed no documented evidence that a care plan was developed to address care related to wandering or being a high elopement risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 3 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Interview with the Registered Nurse Assessment Coordinator on October 12, 2023, at 1:18 p.m. confirmed that Resident 26 did not have a care plan developed to address care related to being a high elopement risk and should have. 28 Pa. Code 211.11(d) Resident care plan. Residents Affected - Few 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 4 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for four of 24 residents reviewed (Residents 2, 30, 31, 38). Findings include: A facility policy for care planning, dated January 11, 2023, indicated that if any interdisciplinary team member identified an interim change, the care plan would be adjusted accordingly. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 11, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for her daily care needs. The resident's care plan, most recently updated on July 11, 2023, revealed that the resident was at risk for falls due to her impaired cognition. Physician's orders for Resident 2, dated May 1, 2022, included an order for the resident to receive two fall mats for safety. Observations of Resident 2 on October 10, 2023, at 10:35 a.m. revealed that she was in bed, her bed was low to the ground, and she had two fall mats down. There was no documented evidence that Resident 2's care plan was revised to include that she was in a low bed or that she had two fall mats for safety. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on October 11, 2023, at 1:02 p.m. confirmed that Resident 2's care plan did not contain the low bed or the two fall mats and that it should have. A quarterly MDS assessment for Resident 30, dated September 14, 2023, revealed that the resident was understood and could understand others, required limited assistance with daily care needs, and had diagnoses that included congestive heart failure (heart does not pump blood as well as it should). A care plan for Resident 30, dated June 22, 2023, included that the resident was at risk for weight loss and was to be restricted to 1800 cc of fluids per day. Physician's orders for Resident 30, dated August 17, 2023, included an order to discontinue the 1800 cc (cubic centimeters) per day fluid restriction. Interview with the Registered Nurse Assessment Coordinator on October 12, 2023, at 2:23 p.m. confirmed that the care plan for Resident 30 was not revised when the fluid restriction was discontinued and should have been. An annual MDS for Resident 31, dated August 2, 2023, revealed that the resident was cognitively intact and required extensive assistance for daily care needs. Resident 31's care plan, dated July 18, 2023, revealed that she had intravenous (IV) antibiotics for an infection. A care plan, dated June 1, 2023, revealed that the resident had an indwelling urinary catheter (tube inserted directly into the bladder), 18 French (specific size) with a 10 cubic centimeters (cc) balloon (used to secure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 5 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0657 device within the bladder). Level of Harm - Minimal harm or potential for actual harm Resident 31's Medication Administration Record (MAR) for July 2023 revealed that her IV antibiotics were complete on July 24, 2023. Residents Affected - Some Physician's orders for Resident 31, dated September 27, 2023, included an order for the resident to have an indwelling urinary catheter that was 16 French with a 10 cc balloon. Observations of Resident 31 on October 12, 2023, at 10:53 a.m. revealed that Resident 31's urinary catheter was a 16 French, 10 cc balloon, which matched her physician's order but not her care plan. Interview with the RNAC on October 11, 2023, at 1:55 p.m. confirmed that Resident 31's IV antibiotics were discontinued on July 28, 2023, and that her care plan should have been revised at that time. Interview with Registered Nurse Assessment Coordinator on October 12, 2023, at 11:42 a.m. confirmed that Resident 31's care plan should have been updated to reflect the physician's order regarding the size of her urinary catheter and that it was not. A significant change MDS for Resident 38, dated July 14, 2023, revealed that the resident was cognitively impaired and required extensive assistance for daily care needs. A care plan for Resident 38, dated July 24, 2023, revealed that the resident was at risk for complication from blood thinning medications (Xarelto). A review of Resident 38's Medication Administration Records (MAR), dated July 2023, revealed that the resident's Xarelto was discontinued on July 19, 2023. Interview with RNAC (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on October 12, 2023, at 1:02 p.m. confirmed that Resident 38's care plan should have been updated to reflect the discontinued Xarelto and it was not. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 6 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

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. Based on review of policies, as well as and clinical records and staff interviews, it was determined that the facility failed to ensure that the environment remained as free from accident hazards as possible, by not properly identifying residents with a high risk for elopement for one of 24 residents reviewed (Resident 33). Findings include: A facility policy for elopement, dated January 11, 2023, included that all residents at risk or those demonstrating attempts to leave the unit or building will have a photograph taken and available for all team members to view and use. The interdisciplinary team provides goals and approaches to address the elopement risk. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 33, dated September 14, 2023, revealed that the resident was cognitively impaired, exhibited wandering behaviors, required extensive assistance with daily care needs, and had diagnoses that included Alzheimer's disease. A care plan for Resident 33, dated August 10, 2023, indicated that the resident was a wondering risk due to going in and out of residents' rooms. Interventions included to provide for safety by following elopement risk procedures. A nurse's note for Resident 33, dated October 4, 2023, at 4:22 p.m. revealed that the resident was entering other residents' rooms and taking personal items that did not belong to her. She was noted to be attempting to exit the alarmed doors by the elevator that leads to a stairwell. Interview on October 12, 2023, at 3:00 p.m. with Licensed Practical Nurse 5 confirmed that Resident 33 was not on the elopement risk list that was located in a binder on the unit and last updated on February 24, 2019. Interview with the Registered Nurse Assessment Coordinator on October 11, 2023, at 3:48 p.m. revealed that the elopement binder was no longer used, and in its place an elopement list containing names and photos of residents who are a high risk for elopement were hung at every nurse's station and at different departments throughout the facility. Observations of the elopement lists posted in an administrative office, and at a nurse's station on the first and second floor, were made at this time, and Resident 33 was not on the lists. Interview with the Registered Nurse Assessment Coordinator on October 12, 2023, at 1:19 p.m. confirmed that Resident 33 should have been put on the elopement list when she was identified as a high risk for elopement but was not. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 7 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0689 28 Pa. Code 211.12(d)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 8 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of 24 residents reviewed (Resident 26). Findings include: The facility's policy for Psychotropic Medication Use, dated January 11, 2023, indicated that residents receiving psychotropic (cause changes in mood and behavior) drugs will be monitored for targeted behaviors and side effects. Behavioral approaches are to be utilized prior to giving as needed medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated August 15, 2023, revealed that the resident was understood and able to understand others, required extensive assistance with daily care needs, and had diagnosis that included Alzheimer's disease. Physician's orders for Resident 26, dated August 23, 2023, included an order for the resident to receive 0.25 milligrams (mg) of alprazolam (a psychotropic medication to treat anxiety) every six hours as needed. Review of the Medication Administration Record for Resident 26 for September and October 2023 revealed that the resident was administered 0.25 mg of alprazolam on September 2 at 4:42 p.m., September 11 at 3:57 p.m., September 13 at 3:16 p.m., September 16 at 2:38 p.m., and October 8, at 6:47 p.m. There was no documented evidence that non-pharmalogical behavioral approaches were attempted prior to administering alprazolam on these dates and times. Review of the clinical record for Resident 26 revealed no documented rationale for the long-term use of alprazolam as needed, and as required by federal law. An interview with the Registered Nurse Assessment Coordinator on October 11, 2023, at 2:47 p.m. and again on October 12, 2023, at 1:18 p.m. confirmed that there were no non-pharmalogical interventions attempted prior to the administration of alprazolam on the above dates and times, and there was no documented rationale for the long-term use of alprazolam, per facility policy. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 9 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policies, manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin with the date they were opened in one of two medication carts reviewed (1st Floor Back Medication Cart), failed to ensure that controlled refrigerated medications were stored in a separately locked, permanently affixed container in two of two medication refrigerators reviewed (second floor front and second floor back medication room refrigerators), and failed to label a bottle of testing solution when it was opened in one of two medication room refrigerators reviewed (second floor back medication refrigerator). Findings include: Manufacturer's directions for Insulin Lispro (Humalog - a fast-acting insulin used to lower blood sugar levels), dated November 2019, indicated that opened vials were to be thrown away after 28 days of use, even if there was insulin left in the vial. The facility's policy regarding medication labels, dated January 11, 2023, revealed that each prescription medication label includes expiration date of medication (if not on label, must be on container). Physician's orders for Resident 29, dated October 6, 2023, included an order for the resident to receive Insulin Lispro as per a sliding scale (the amount of Insulin given was determined by the blood sugar level) three times per day. Observations of the 1st Floor Back Medication Cart on October 11, 2023, at 8:35 a.m. revealed that Resident 29's Insulin Lispro Pen Injector was not labeled with the date it was opened. Interview with Licensed Practical Nurse 6 at the time of observation confirmed that Resident 29's Insulin Lispro Pen Injector was not labeled with the date it was opened. Interview with the Director of Nursing on October 12, 2023, at 2:30 p.m. confirmed that the Insulin Lispro Pen Injector should have been dated with the date that it was opened. Physician's orders for Resident 16, dated September 12, 2023, included an order for the resident to receive 1 milligram (mg) of ABHR (compound of controlled medications that include Lorazepam, diphenhydramine, haloperidol, and metoclopramide used together to treat nausea, vomiting or agitation) gel topically every day for anxiety and agitation. Physician's orders for Resident 31, dated July 18, 2023, included an order for the resident to receive 0.5 mg of Ativan Intensol (antianxiety medication that is a controlled dug) 2 mg/milliliter (ml) every four hours as needed for agitation. Physician's orders for Resident 33, dated July 18, 2023, included an order for the resident to receive 0.5 ml of Ativan Intensol 2 mg/ml at bedtime daily and every four hours as needed for restlessness or anxiety. Observations on October 12, 2023, at 12:00 p.m. of the medication refrigerator in the second-floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 10 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some front medication room revealed 14 doses of ABHR gel in a bag labeled for Resident 16 and a bottle of Ativan Intensol labeled for Resident 31 lying on a shelf in the refrigerator and not stored separately from other refrigerated medications. A separate locked box was not present in the refrigerator. Interview with Licensed Practical Nurse 7 at that time revealed that medications were double locked because they were in a locked refrigerator in a locked room, but the controlled drugs were not in a separate container from other medications. Observations on October 12, 2023, at 12:10 p.m. of the medication refrigerator in the second floor back medication room revealed two bottles of Ativan Intensol labeled for Resident 33 on a shelf in the refrigerator and not stored separately from other refrigerated medications. There was an attached locked box in the refrigerator that was not being used. Interview with Licensed Practical Nurse 2 at that time confirmed that the locked box was not being used to store controlled refrigerated medications. The manufacturer's instructions for Aplisol (a solution injected under the skin to test for tuberculosis - a lung infection) revealed that vials in use more than 30 days should be discarded due to possible oxidation (exposure to oxygen causing it to lose its properties) and degradation (breakdown of the substance causing it to lose its quality), which may affect potency. Observations on October 12, 2023, at 12:10 p.m. of the medication refrigerator in the second floor back medication room revealed one opened bottle of Aplisol on the door of the refrigerator without the date opened to determine when the medication should be discarded. Interview on October 12, 2023, at 12:10 p.m. with Licensed Practical Nurse 2 confirmed that the bottle of Aplisol in the refrigerator was opened and was not dated to identify when the medication should be discarded, and it should have been. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 11 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of clinical records and interviews with staff, it was determined that the facility failed to maintain clinical records that were complete for one of 24 residents reviewed (Resident 29). Residents Affected - Some Findings include: An Annual Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 29, dated July 18, 2023, revealed that the resident was understood and could understand, required extensive assistance for all care, and had a diagnosis of diabetes (a group of diseases that result in too much sugar in the blood). A care plan for the resident, dated August 14, 2023, indicated that the resident had diabetes and that staff were to administer medications as ordered by the physician. A care plan for the resident, dated September 9, 2023, indicated that the resident was to participate with the restorative nurse program (helps residents practice activities of daily living to improve, or at least maintain, overall functioning) for ambulating related to the inability to ambulate without assistance and risk of decline. The resident was to ambulate 50 feet using a gait belt (an assistance safety device that can be used to help a resident sit, stand, or walk around, as well as to transfer) and folding wheeled walker with the assist of one and with a wheelchair to follow. The resident was to complete the program two times a day seven days a week and if the resident refused, staff was to re-offer again on their shift. Physician's orders for Resident 29, dated October 6, 2023, included an order for the resident to receive Insulin Lispro (Humalog - a fast-acting insulin used to lower blood sugar levels) one unit for a blood sugar of 150 through 200 milligram/deciliter (mg/dL); two units for a blood sugar 201 through 250 mg/dL; four units for a blood sugar of 251 through 300 mg/dL; six units for a blood sugar of 301 through 350 mg/dL; 10 units for a blood sugar of 351 through 400 mg/dL; and to hold for a blood sugar of 401 through 600 mg/dL. Resident 29's Medication Administration Records (MAR's) for October 2023 revealed that on October 7, 2023, at 11:30 a.m. the blood sugar level was documented as 306 mg/dL; on October 7, 2023, at 4:30 p.m. the blood sugar level was documented as 273 mg/dL; on October 9, 2023, at 11:30 a.m. the blood sugar level was documented as 395 mg/dL; on October 11, 2023, at 7:30 a.m. the blood sugar level was documented as 307 mg/dL; and on October 11, 2023, at 11:30 a.m. the blood sugar level was documented as 359 mg/dL. The Insulin Lispro was signed as given; however, there was no documented evidence in Resident 29's clinical record to indicate the amount of Insulin Lispro that was given on the above dates and times. Interview with Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on October 12, 2023, at 10:55 a.m. confirmed that there was no documented evidence in Resident 29's clinical record to indicate the amount of Insulin that was administered on the above dates. A nursing note for Resident 29, dated March 13, 2023, revealed that the ambulation restorative program was initiated and is as follows. The resident is to walk 50 feet with limited assist of one, a gait belt, and wheelchair to follow twice a day seven days per week. Staff was educated and all parties are aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 12 of 13 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 395427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A therapy discharge readiness/restorative nursing program for Resident 29, dated August 30, 2023, revealed that the resident was to ambulate up to 50 feet with a folding wheeled walker, with the assist of one with a gait belt, and with a wheelchair to follow. Ambulation restorative nursing program documentation for Resident 29, dated September 2023, revealed no documented evidence that the ambulation restorative nursing program had been completed and/or refused during the a.m. shifts on September 12, 13, 14 and 15, 2023, and during the p.m. shifts on September 5, 8 and 13, 2023. Interview with the RNAC on October 12, 2023, at 11:40 a.m. confirmed that there was no documented evidence that Resident 29's ambulation restorative nursing program had been completed and/or refused on the above dates. She indicated that staff should be documenting if the resident completed, refused, or was unable to complete the program. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395427 If continuation sheet Page 13 of 13

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Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0600SeriousS&S Gactual harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0758GeneralS&S Epotential for harm
F758 - Medication Errors
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.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0657GeneralS&S Epotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0842GeneralS&S Epotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the October 12, 2023 survey of LUTHERAN HOME AT HOLLIDAYSBURG?

This was a inspection survey of LUTHERAN HOME AT HOLLIDAYSBURG on October 12, 2023. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LUTHERAN HOME AT HOLLIDAYSBURG on October 12, 2023?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·October 12, 2023