Health inspection·January 4, 2024

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 clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of 22 residents reviewed (Residents 1 and 77). Findings Include: Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking). During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. Resident stated that when he bites down, it causes pain in his lower gum. Resident stated he hadn't been seen by a dentist while at the facility. Observation on January 2, 2024, at 10:01 AM, Resident 1 was wearing full upper dentures, his bottom jaw was edentulous, and his gums were reddened. Resident 1's December 2023 physician orders included Orajel Mouth/Throat Gel 10 % (Benzocaine (Dental)- topical pain killer) Give one application orally three times a day for Oral ulcers, start date December 1, 2023. Resident 1's December 2023 Medication Administration Record (MAR - documentation of medication administered) documented Orajel was administered orally three times a day for oral ulcers, started December 1, 2023; and First-mouthwash BLM mouth/throat suspension (magic mouthwash- medication used to treat oral ulcers and mouth pain) was administered one time a day for mouth ulcer December 12, 2023, through December 18, 2023; administered as ordered. Review of Resident 1's progress notes documented on December 1, 2023, revealed the Resident complained of oral pain/discomfort, nurse noted small red inflamed areas to upper and lower gums under denture lining, and the physician was made aware and ordered Orajel three times a day until healed. Further review of progress notes documented on December 11, 2023, Certified Registered Nurse Practitioner ordered magic mouthwash for ulcers in Resident 1's mouth for seven days. Review of nursing note on December 27, 2023 documented the Resident receiving Orajel for recent mouth sores. Review of Resident 1 care plan on January 2, 2023, failed to include documentation of dentures and mouth pain/ulcers. During an interview with the Director of Nursing (DON) on January 3, 2024, at 1:10 PM, it was revealed that Resident 1 has upper and lower dentures and is able to care for his dentures himself. Further review of Resident 1's care plan on January 4, 2024, documented a focus area for dental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395612 If continuation sheet Page 2 of 7 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 395612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Sprenkle Drive 1801 Folkemer Circle York, PA 17404 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 health problems due to injury related to dentures with complaint of mouth pain, initiated on January 3, 2024; with interventions that included mouth inspections as needed, report changes to nurse, and to observe/document/report to provider signs or symptoms of dental problems. During an interview with the DON on January 4, 2024, at 10:36 AM, it was revealed a dental care plan should've been initiated prior to January 3, 2024. Review of Resident 77's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD- acid reflux) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Review of Resident 77's current physician orders, revealed an order dated September 21, 2023, for a hospice consult evaluation and treatment. Review of Resident 77's progress notes revealed a note dated September 28, 2023, stating that Resident 77 is on hospice services as of September 28, 2023. Review of Resident 77's significant change MDS (Minimum Data Set- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated October 11, 2023, revealed that Resident 77 was marked as receiving hospice services. Review of Resident 77's current care plan failed to reveal a hospice care plan. On January 3, 2024, at 1:13 PM, the DON provided a hospice care plan for Resident 77 that was initiated on January 3, 2024. At that time, the DON stated that the hospice care plan should have been initiated prior to this date. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395612 If continuation sheet Page 3 of 7 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 395612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Sprenkle Drive 1801 Folkemer Circle York, PA 17404 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 - Few 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 staff interviews, record review, and facility policy review, it was determined that the facility failed to ensure that the comprehensive care plan was revised to include changes in the resident's status and plan of care for one of 19 residents reviewed (Resident 26). Findings include: Review of the facility policy, titled Comprehensive Care Plan Standard, last reviewed July 2023, revealed that it requires the resident's care plan to be reviewed and revised, if applicable, by the interdisciplinary team after each annual and quarterly assessment. Review of Resident 26's clinical record on January 2, 2024, revealed diagnoses that include diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and hypertension (elevated blood pressure). Review of the current care plan on January 3, 2024, at 10:30 AM, revealed a care plan for pain related to lower left leg cellulitis (bacterial skin infection). Resident 26 was admitted with a diagnosis of cellulitis on July 2, 2022, and the cellulitis was resolved after treatment with antibiotics. The cellulitis was never removed from the care plan. During an interview with the Nursing Home Administrator and Clinical Consultant on January 4, 2024, at 10:30 AM, both were in agreement that the care plan should have been revised to remove the cellulitis diagnosis. 28 Pa. Code 211.12(d)(1)(3)Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395612 If continuation sheet Page 4 of 7 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 395612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Sprenkle Drive 1801 Folkemer Circle York, PA 17404 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Dental Services policy, observations, staff and resident interviews, and record review, it was determined that the facility failed to provide routine and emergency dental services for one of 22 residents reviewed (Resident 1). Residents Affected - Few Findings: Review of the facility's Dental Services policy, revised November 28, 2017, read, in part, the facility must assist residents in obtaining routine and emergency dental care. Routine services include an annual inspection of the oral cavity including fitting dentures. Emergency dental services includes treatment of acute pain of teeth or gums by a dentist. Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking). During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. The Resident stated that when he bites down, it causes pain in his lower gum. Resident stated he hadn't been seen by a dentist while at the facility. Observation on January 2, 2024, at 10:01 AM, revealed Resident 1 was wearing full upper dentures, his bottom jaw was edentulous, and his gums were reddened. On January 2, 2024, review of Resident 1's clinical record revealed he was admitted to the facility on [DATE], payor source as of October 14, 2023, was Community Heath Choices AmeriHealth caritas (Pennsylvania medical assistance managed care health plan), and was cognitively intact per Brief Interview For Mental Status (BIMS- a test to evaluate cognition) score of 14, completed on December 28, 2023. Resident 1's December 2023 physician orders included: consult podiatry, vision, dental and audiology services as ordered (360Care Podiatry, vision, dental), start date February 3, 2023; and Orajel Mouth/Throat Gel 10 % (Benzocaine (Dental)- topical pain killer) Give one application orally three times a day for Oral ulcers, start date December 1, 2023. Resident 1's December 2023 Medication Administration Record (documentation of medication administered) documented Orajel was administered orally three times a day for oral ulcers, started December 1, 2023; and First-mouthwash BLM mouth/throat suspension (magic mouthwash - medication used to treat oral ulcers and mouth pain) was administered one time a day for mouth ulcer December 12, 2023, through December 18, 2023; administered as ordered. Review of Resident 1's progress notes documented on December 1, 2023, revealed the Resident complained of oral pain/discomfort, nurse noted small red inflamed areas to upper and lower gums under denture lining, physician was made aware and ordered Orajel three times a day until healed. Further review of progress notes documented on December 11, 2023, Certified Registered Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395612 If continuation sheet Page 5 of 7 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 395612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Sprenkle Drive 1801 Folkemer Circle York, PA 17404 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 0791 Practitioner ordered magic mouthwash for ulcers in Resident 1's mouth for seven days. Level of Harm - Minimal harm or potential for actual harm Review of nursing note on December 27, 2023, documented the Resident receiving Orajel for recent mouth sores. Residents Affected - Few During an interview with the Nursing Home Administrator (NHA) on January 3, 2024, at 11:10 AM, it was revealed that, per 360Care, prepayment is needed before scheduling an appointment. During an interview with the Director of Nursing (DON) on January 3, 2023, at 1:10 PM, it was revealed that Resident 1 has upper and lower dentures, and is able to care for his dentures himself. It was also revealed that the physician followed-up with Resident 1 regarding his pain in his lower jaw. DON stated that there wasn't a white patch on Resident 1's lower jaw. DON reiterated that the facility provided information stating 360Care required prepayment before scheduling an appointment. Resident 1's lower gum line slightly erythematous with no open area. Recommendation made to keep lower denture out between meals, continue use of Orajel and follow-up with dentist to evaluate need for new dentures. this seems out of place or needs more info? Interview with Corporate Nurse on January 3, 2024, at 2:40 PM, revealed that, with the new contract, 360Care does require prepayment for residents who are Medicaid pending. Census documentation revealed Resident 1 was Medicaid pending September 16, 2022, through December 21, 2022, then was on skilled services October 22, 2022, through October 13, 2023, and was on Medicaid services as of October 14, 2023. During an interview with NHA on January 3, 2024, at 2:40 PM, it was revealed that he wasn't aware that Resident 1 was in emergent need to see a dentist. Resident 1 is able to eat and has not lost weight. Resident 1's family opted for dental services to be on hold until Resident 1 was on Medicaid. The dentist requires prepayment for services for certain payor sources. During an interview with the DON and Employee 7 (Unit Manager) on January 4, 2024, at 11:20 AM, it was revealed that Resident 1 wasn't on Medicaid until October 14, 2023, the family wasn't willing to prepay for routine dental services, and the family opted to wait until Resident 1 was on Medicaid services. It was also revealed that dental pain would not be considered need for emergent dental services, and the physician was managing and monitoring Resident's dental health. It was confirmed that the dentist is expected in the facility March 2024, the dental office should be aware that Resident 1's payor source was Medicaid, and should be scheduled for a routine dental visit; however, they weren't able to confirm that Resident 1 was on the dentist schedule to be seen March 2024. During the interview with DON and Employee 7 on January 4, 2024, at 12:00 PM, revealed Resident 1 was not seen for routine dental due to having dentures without concerns and not being active on Medicaid. It was also revealed that Resident 1 is scheduled to be seen by the facility dentist on February 28, 2024, at 9:00 AM. The facility failed to provide routine and emergent dental services in a timely manner as evidence by treatment for dental pain initiated December 1, 2023, with additional intervention December 11, 2023. Further, the facility failed to evaluate/monitor Resident 1's oral health and dental pain prior to surveyor questioning Resident 1's oral pain and, at that point, the physician did complete a follow-up visit on January 3, 2024, recommending Resident 1 be seen by a dentist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395612 If continuation sheet Page 6 of 7 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 395612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Sprenkle Drive 1801 Folkemer Circle York, PA 17404 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 0791 28 Pa Code 211.15 Dental 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: 395612 If continuation sheet Page 7 of 7