Health inspection·December 10, 2025

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 26 residents reviewed (Residents 32).Findings include:An admission note for Resident 32 dated October 14, 2025, at 6:31 p.m. revealed that the resident arrived at the facility at 5:25 p.m., was alert and oriented and had a midline surgical incision (vertical cut made down the center of the abdomen) that was closed with a VAC dressing (Vacuum-Assisted Closure dressing- a medical device that uses a vacuum pump to apply suction to a wound, promoting healing). Physician's orders for Resident 32 dated October 14, 2025, included for the resident to have his wound VAC settings and all connections checked every four hours, be administered two 500 milligram (mg) capsules of Amoxicillin (an antibiotic medication) twice a day, and be administered 500 mg of Clarithromycin (an antibiotic medication) twice a day for surgical aftercare following surgery on the digestive system. There was no documented evidence that a baseline care plan was developed for Resident 32's care and treatment needs related to having a wound VAC dressing and for antibiotic use. Interview with the Director of Nursing on October 22, 2025, at 2:51 p.m. confirmed that the resident's baseline care plan did not include care and treatment needs required for the resident's wound VAC and for antibiotic use. 28 Pa. Code 211.12(d)(1) Nursing Services Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 26 residents reviewed (Residents 32).Findings include:An admission note for Resident 32 dated October 14, 2025, at 6:31 p.m. revealed that the resident arrived at the facility at 5:25 p.m., was alert and oriented and had a midline surgical incision (vertical cut made down the center of the abdomen) that was closed with a VAC dressing (Vacuum-Assisted Closure dressing- a medical device that uses a vacuum pump to apply suction to a wound, promoting healing). Physician's orders for Resident 32 dated October 14, 2025, included for the resident to have his wound VAC settings and all connections checked every four hours, be administered two 500 milligram (mg) capsules of Amoxicillin (an antibiotic medication) twice a day, and be administered 500 mg of Clarithromycin (an antibiotic medication) twice a day for surgical aftercare following surgery on the digestive system. There was no documented evidence that a baseline care plan was developed for Resident 32's care and treatment needs related to having a wound VAC dressing and for antibiotic use. Interview with the Director of Nursing on October 22, 2025, at 2:51 p.m. confirmed that the resident's baseline care plan did not include care and treatment needs required for the resident's wound VAC and for antibiotic use. 28 Pa. Code 211.12(d)(1) Nursing Services Page 1 of 15 395427 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

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 on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for one of 26 residents reviewed (Resident 22).Findings include:A quarterly MDS assessment for Resident 22 dated July 13, 2025, indicated that the resident was cognitively impaired, had clear speech, was usually understood, could rarely understand, required assistance with daily care needs, was always incontinent of bowel, and had diagnoses that included dementia. Current physician's orders for Resident 22, included an order for the resident to receive 5 ounces (oz) of Fiberjuice (laxative- used to produce a bowel movement) as needed for constipation if no bowel movement by the second day. Resident 22's bowel movement records dated September and October, 2025 indicated that the resident did not have a bowel movement on September 4, 2025, through September 7, 2025. There was no documented evidence that 5 ounces (oz) of Fiberjuice was offered to or refused by the resident after the second day of no bowel movement. The resident did not have a bowel movement on October 6, 2025, through October 10, 2025. There was no documented evidence that 5 ounces (oz) of Fiberjuice was offered to or refused by the resident after the second day of no bowel movement.Interview with the Director of Nursing on October 23, 2025, at 10:17 confirmed that the staff did not follow the facility's bowel policy and physicians orders for Resident 22 on the above-mentioned dates.28 Pa. Code 211.12(d)(5) Nursing Services. Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for one of 26 residents reviewed (Resident 22).Findings include:A quarterly MDS assessment for Resident 22 dated July 13, 2025, indicated that the resident was cognitively impaired, had clear speech, was usually understood, could rarely understand, required assistance with daily care needs, was always incontinent of bowel, and had diagnoses that included dementia. Current physician's orders for Resident 22, included an order for the resident to receive 5 ounces (oz) of Fiberjuice (laxative- used to produce a bowel movement) as needed for constipation if no bowel movement by the second day. Resident 22's bowel movement records dated September and October, 2025 indicated that the resident did not have a bowel movement on September 4, 2025, through September 7, 2025. There was no documented evidence that 5 ounces (oz) of Fiberjuice was offered to or refused by the resident after the second day of no bowel movement. The resident did not have a bowel movement on October 6, 2025, through October 10, 2025. There was no documented evidence that 5 ounces (oz) of Fiberjuice was offered to or refused by the resident after the second day of no bowel movement.Interview with the Director of Nursing on October 23, 2025, at 10:17 confirmed that the staff did not follow the facility's bowel policy and physicians orders for Resident 22 on the above-mentioned dates.28 Pa. Code 211.12(d)(5) Nursing Services. Residents Affected - Few 395427 Page 2 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records as well as staff interviews, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice, by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician for one of 26 residents reviewed (Resident 13) who had pressure ulcers.Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated September 29, 2025, indicated that the resident was cognitively intact and had a pressure ulcers (skin breakdown caused by pressure). A wound clinic note, dated September 25, 2025, revealed that Resident 13 had a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle.) to the left lateral maleolus (outer ankle), the bone was palpable, and a treatment of collagen powder (a type of medical dressing used to promote wound healing using purified collagen, a protein that is essential for skin and tissue repair) mixed with bacitracin (topical antibiotic) was to be applied every other day and as needed. A wound clinic note, dated October 9, 2025, revealed that Resident 13's pressure ulcer on the the left lateral maleolus was larger upon her hospital return and had undermining (break down under the skin) from 4 o'clock to 7 o'clock. It was recommended to change the treatment to the left lateral maleolus and apply a collagen sheet to the base of the wound to include undermining and apply Hydrogel (moist wound care products that provide hydration, pain relief and infection prevention) to the base of the wound every other day and as needed. A wound clinic note, dated October 16, 2025, revealed that Resident 13's pressure ulcer on the left lateral malleolus was improving and it was recommended to continue the collagen sheet to the base of the wound to include undermining and apply Hydrogel to the base of the wound every other day and as needed. A review of Resident 13's Treatment Administration Record (TAR) for October 2025 revealed that the resident continued to receive collagen powder mixed with Bacitracin and did not receive the Hydrogel as recommended from the wound clinic.Interview with the Director of Nursing on October 21, 2025, at 10:38 a.m. confirmed that the wound recommendations on October 9 and 16, 2025 were not followed.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.Based on review of clinical records as well as staff interviews, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice, by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician for one of 26 residents reviewed (Resident 13) who had pressure ulcers.Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated September 29, 2025, indicated that the resident was cognitively intact and had a pressure ulcers (skin breakdown caused by pressure). A wound clinic note, dated September 25, 2025, revealed that Resident 13 had a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle.) to the left lateral maleolus (outer ankle), the bone was palpable, and a treatment of collagen powder (a type of medical dressing used to promote wound healing using purified collagen, a protein that is essential for skin and tissue repair) mixed with bacitracin (topical antibiotic) was to be applied every other day and as needed. A wound clinic note, dated October 9, 2025, revealed that Resident 13's pressure ulcer on the the left lateral maleolus was larger upon her hospital return and had undermining (break down under the skin) from 4 o'clock to 7 o'clock. It was recommended to change the treatment to the left lateral maleolus and apply a collagen sheet to the base of the wound to include undermining and apply Hydrogel (moist wound care products that provide hydration, pain relief and infection prevention) to the base of the wound every other day and as needed. A wound clinic note, dated October 16, 2025, revealed that Resident 13's pressure ulcer on the left lateral malleolus was improving and Residents Affected - Few 395427 Page 3 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it was recommended to continue the collagen sheet to the base of the wound to include undermining and apply Hydrogel to the base of the wound every other day and as needed. A review of Resident 13's Treatment Administration Record (TAR) for October 2025 revealed that the resident continued to receive collagen powder mixed with Bacitracin and did not receive the Hydrogel as recommended from the wound clinic.Interview with the Director of Nursing on October 21, 2025, at 10:38 a.m. confirmed that the wound recommendations on October 9 and 16, 2025 were not followed.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395427 Page 4 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of nurses aides dates of hire and their most recent performance review dates, it was determined that the facility failed to complete annual nurse aide performance evaluations for two of three nurse aides reviewed (Nurse Aides 1 and 2).Findings include:A list of nurse aides provided by the facility revealed that Nurse Aide 1 was hired on May 23, 2000. Based on her date of hire, an annual performance evaluation was due in May, 2025. However, there was no documented evidence that the annual performance evaluation was completed as required.Nurse Aide 2 was hired on June 21, 2022. Based on her date of hire, an annual performance evaluation was due in June, 2025. However, there was no documented evidence that the annual performance evaluation was completed as required.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aides 1 and 2 did not have an annual performance evaluations. 28 Pa. Code 201.18(e)(1) Management. Residents Affected - Few 395427 Page 5 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of 26 residents reviewed (Resident 34).Findings include:A facility policy for medication and treatment administration dated September 5, 2025, indicated that medications are administered in accordance with prescriber orders, including any required time frame.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34 dated October 8, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs and had diagnoses that included atrial fibrillation (a heart rhythm disorder characterized by a rapid and irregular heartbeat) and aneurysm of an artery in the lower extremity (an enlargement or weakened area in a blood vessel in the leg). Hospital discharge records for Resident 34 dated September 4, 2025, included physician's orders to administer 50 mg of enoxaparin (a blood thinner medication) once daily until the resident's international normalized ratio (INR-a test that measures the amount of time taken for your blood to clot-used to monitor the effectiveness of blood-thinning medications).Review of laboratory results for Resident 34 dated September 17, 2025, revealed that the resident's INR was 2.8 and the INR therapeutic range for high intensity therapy was 2.5-3.5. A review of the Medication Administration Record (MAR) for Resident 34 dated September 2025, revealed that 50 mg of enoxaparin was administered on September 17, 18, and 19. Interview with the Director of Nursing on October 21, 2025, at 4:17 p.m. confirmed that Resident 34's INR was in therapeutic range on September 17, 2025, and enoxaparin should have been discontinued on September 17, however, it was not, and the enoxaparin was administered on September 18 and 19, 2025 when it should not have been. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Residents Affected - Few 395427 Page 6 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food service safety.Findings include:The facility's dietary policy regarding food storage, dated September 5, 2025, revealed that to prevent cross contamination, food should be properly stored. Raw meat, raw eggs, and poultry should be separate from ready to eat and prepared foods. Observations in the kitchen on October 20, 2025, at 9:12 a.m. revealed that in the walk in cooler there was a roll of frozen raw ground [NAME] thawing on a tray. Below the tray of raw [NAME] was a container labeled cooked ground beef for chili.Interview with Dietary Aide 3 on October 20, 2025, at 9:26 a.m., revealed that he should have moved the raw thawing [NAME] to the bottom shelf below the cooked prepared [NAME].Interview with the Dietary Director on October 20, 2025, at 9:25 a.m. confirmed that the cooked [NAME] should not have been placed below the raw hamburger.28 Pa. Code 211.6(f) Dietary services. 395427 Page 7 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on review of job descriptions, facility documents and staff interviews, it was determined that the facility failed to provide Communication training to three of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 4's personnel file revealed that she was hired on October 23, 2014. Review of her continuing education transcript revealed that she did not have any education regarding effective communication.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding effective communication.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding effective communication.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 4, Nurse Aide 1 and Licensed Practical Nurse 5 failed to complete the necessary education regarding effective communication. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development 395427 Page 8 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Resident Rights training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding resident rights Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding resident rights.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1 and Licensed Practical Nurse 5 failed to complete the necessary education regarding resident rights for the current year. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development 395427 Page 9 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide abuse, neglect, and exploitation training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding abuse, neglect, and exploitation.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding abuse, neglect, and exploitation.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1, and Licensed Practical Nurse 5 failed to complete the necessary education regarding abuse, neglect, and exploitation. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development 395427 Page 10 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to three of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 4's personnel file revealed that she was hired on October 23, 2014. Review of her continuing education transcript revealed that she did not have any education regarding Quality Assurance and Performance Improvement (QAPI) training.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding Quality Assurance and Performance Improvement (QAPI) training.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding Quality Assurance and Performance Improvement (QAPI) training.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aides 4 and 1, and Licensed Practical Nurse 5 failed to complete the necessary education regarding Quality Assurance and Performance Improvement (QAPI) training. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development 395427 Page 11 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding infection control.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding infection control.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1 and Licensed Practical Nurse 5 failed to complete the necessary education regarding infection control. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development 395427 Page 12 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide compliance and ethics training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding compliance and ethics.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding compliance and ethics.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1 and Licensed Practical Nurse 5 failed to complete the necessary education regarding compliance and ethics. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development Residents Affected - Few 395427 Page 13 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for one of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have the required 12 hours of Nurse Aide training per year.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1 failed to complete the necessary 12 hours of training. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development 395427 Page 14 of 15 395427 12/10/2025 Lutheran Home at Hollidaysburg 916 Hickory Street Hollidaysburg, PA 16648

F 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Behavioral Health training to three of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 4's personnel file revealed that she was hired on October 23, 2014. Review of her continuing education transcript revealed that she did not have any education regarding behavioral health.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding behavioral health.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding behavioral health.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 4, Nurse Aide 1, and Licensed Practical Nurse 5 failed to complete the necessary education regarding behavioral health.28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development 395427 Page 15 of 15