Health inspection·June 12, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, review of facility provided call bell monitoring system reports, and resident and staff interviews, it was determined that the facility failed to ensure a prompt response time to resident call bells for four of four residents reviewed (Residents 2, 3, 4, and 30) between March 10, 2025, through June 10, 2025. Residents Affected - Some Findings include: Review of the facility policy, titled Call Light, Use of, with a last revised date of May 18, 2018, and a last review date of July 18, 2024, revealed All Center team members must be aware of call lights at all times. Answer ALL call lights promptly whether or not you are assigned to the resident. Answer call lights in a prompt, calm, courteous manner. Once care needs are started, call light is turned off. If additional needs are identified after call bell is turned off, call bell will be reactivated until those needs can be met. During an interview with Resident 2 on June 9, 2025, at 12:56 PM, he indicated that the facility seems short of help at night and that call bell wait times vary. Review of facility's RESPONDER 5000 (call bell monitoring system) reports for Resident 2 revealed the following response times that were greater than 20 minutes: March 15, 2025, at 2:19 PM, 37 minutes; March 19, 2024, at 8:44 PM, 25 minutes; March 24, 2025, at 5:56 AM, 24 minutes; April 3, 2025, at 7:55 PM, 33 minutes; April 18, 2025, at 7:56 PM, 1 hour and 8 minutes; April 21, 2025, at 2:14 PM, 32 minutes; April 29, 2025, at 8:13 PM, 25 minutes; May 5, 2025, at 6:52 AM, 1 hour and 44 minutes; May 27, 2025, at 8:03 PM, 24 minutes; Page 1 of 14 395647 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0558 June 2, 2025, at 6:54 AM, 39 minutes; and Level of Harm - Minimal harm or potential for actual harm June 8, 2025, at 8:20 PM, 28 minutes. Residents Affected - Some Review of facility's RESPONDER 5000 (call bell monitoring system) reports for Resident 3 revealed the following response times that were greater than 20 minutes; March 21, 2025, at 10:26 PM, 25 minutes; March 23, 2025, at 7:38 PM, 23 minutes; March 24, 2025, at 8:50 AM, 31 minutes; March 29, 2025, at 11:14 AM, 28 minutes; March 30, 2025, at 9:20 AM, 42 minutes; March 30, 2025, at 12:45 PM, 42 minutes; April 3, 2025, at 9:03 PM, 21 minutes; April 12, 2025, at 11:46 AM, 37 minutes; April 13, 2025, at 11:23 AM, 23 minutes; April 14, 2025, at 6:58 PM, 21 minutes; April 26, 2025, at 12:06 PM, 40 minutes; April 27, 2025, at 10:43 AM, 30 minutes; April 28, 2025, at 9:01 PM, 24 minutes; May 2, 2025, at 9:53 AM, 22 minutes; May 18, 2025, at 9:02 PM, 23 minutes; May 19, 2025, at 11:51 AM, 29 minutes; May 24, 2025, at 12:49 PM, 27 minutes; May 25, 2025, at 8:07 PM, 23 minutes; June 7, 2025, at 10:30 AM, 29 minutes; June 8, 2025, at 11:41 AM, 35 minutes; and June 8, 2025, at 9:01 PM, 24 minutes. 395647 Page 2 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with Resident 4 on June 10, 2025, at 9:36 AM, she indicated there is not enough staff; she has been on bedpan 45 minutes to 2 hours; all shifts have issues, but day shift and evening shift are the worst. Review of facility's RESPONDER 5000 (call bell monitoring system) reports for Resident 4 revealed the following response times that were greater than 20 minutes: March 10, 2025, at 10:25 AM, 31 minutes; March 15, 2025, at 9:29 AM, 28 minutes; March 16, 2025, at 9:18 AM, 50 minutes; March 25, 2025, at 2:26 PM, 21 minutes; April 10, 2025, at 2:10 PM, 26 minutes; April 17, 2025, at 8:30 AM, 21 minutes; April 26, 2025, at 8:59 AM, 27 minutes; April 27, 2025, at 12:47 PM, 24 minutes; May 17, 2025, at 9:31 PM, 24 minutes; and May 27, 2025, at 1:28 PM, 24 minutes. During an interview with Resident 30 on June 9, 2025, at 10:44 AM, she indicated there are long call bell wait times especially on the weekend and she often does not drink enough because she cannot wait for help to take her to the bathroom. Review of facility's RESPONDER 5000 (call bell monitoring system) reports for Resident 30 revealed the following response times that were greater than 20 minutes: May 11, 2025, at 7:44 AM, 44 minutes; May 11, 2025, at 8:44 AM, 22 minutes; May 11, 2025, at 7:20 PM, 34 minutes; May 19, 2025, at 6:55 PM, 24 minutes; and May 25, 2025, at 6:55 AM, 21 minutes. During a staff interview with the Nursing Home Administrator (NHA) on June 12, 2025, at 11:00 AM, the NHA indicated that she reviews call bell reports when a grievance is filed or if resident voices a concern. She indicated that individual long wait times on the reports could just be outliers because a staff member may have forgotten to turn off the call light when need was met, staff may have been involved in another resident's care or passing meal trays. She indicated that all staff are 395647 Page 3 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0558 Level of Harm - Minimal harm or potential for actual harm expected to respond to a call light, but they have been educated not to turn off the call light until the actual need has been met. She said she could not confirm that staff had or had not acknowledged Residents 2, 3, 4, or 30 in a timely manner. She indicated that she looks at the average response time when a concern is voiced and not the individual response times. She said she could not speak as to if anyone else reviews the call bell reports for concerns on a regular basis. Residents Affected - Some During a final staff interview with the NHA and the Director of Nursing on June 12, 2025, at approximately 11:30 AM, they were unable to share the expectations of how long a resident should wait for a response from staff after placing there call bell on for assistance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa Code 211.12(d)(1) Nursing services 395647 Page 4 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of 15 residents reviewed (Residents 14 and 94). Residents Affected - Few Findings include: Review of facility policy, titled Residents Self-Administration of Medication, last reviewed July 18, 2024, revealed Residents are permitted to self-administer medication upon an order from a licensed provider and after evaluation by the Care Planning Team. Review of Resident 14's clinical record revealed diagnoses that included myasthenia gravis with acute exacerbation (an autoimmune disorder of the neuromuscular junction) and muscle weakness (lack of strength). Observations made during medication administration on June 11, 2025, at 12:00 PM, revealed Employee 3 left Resident 14's medications (acetaminophen 650 mg, ferrous sulfate 325 mg) on the bedside table when leaving the room to retrieve additional medication from the medication cart. Upon returning to the room, Resident 14 was observed to have partially taken the medications left on the bedside table. Review of Resident 14's physician orders failed to reveal an order for self-administration of medications. Further review of Resident 14's clinical record revealed a form, titled Self-Administration of Medications Evaluation Form dated March 25, 2025. Review of the form revealed resident 14 was only approved for self-administration of saline nasal spray. During an interview on June 12, 2025, at 1:49 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the DON revealed it was the expectation of the facility that nurses do not leave medications at the bedside if a resident is not assessed to self-administer the medications. Review of Resident 94's clinical record revealed diagnoses that included Huntington disease (genetic disorder that causes the progressive breakdown of nerve cells in the brain) and encounter for palliative care (specialized medical care that focuses on providing comfort and support to patients with serious or life-threatening illnesses). Further review of Resident 94's clinical record revealed she was admitted to the facility on [DATE], for respite hospice care. Review of Resident 94's physician orders failed to reveal an order for hospice services. Review of Resident 94's care plan revealed a focus area for comfort/hospice care with interventions that provided contact details for Resident 94's hospice provider. During an interview on June 11, 2025, at 1:51 PM, with the NHA and DON, the NHA stated Resident 94 now has a physician's order for hospice care and that it was the facility's expectation that 395647 Page 5 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0658 physician orders for care and services be entered. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few 395647 Page 6 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

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 clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 13). Residents Affected - Few Findings include: Review of Resident 13's clinical record revealed diagnoses that included cervicalgia (neck pain) and acute diastolic congestive heart failure (occurs when the heart muscle becomes stiff and unable to relax properly between beats). During an interview on June 9, 2025, at 1:26 PM, with Resident 13, it was revealed that Resident 13 had a wound on her right hip and was receiving daily wound care. Further review of Resident 13's clinical record revealed Resident 13's was evaluated by a contracted wound care provider on June 4, 2025. Review of the evaluation revealed Resident 13 had a stage 1 pressure ulcer on the right buttock that was present for less than two days. Treatment recommendations for superabsorbent gelling fiber with silicone border and faced once daily and as needed for 30 days were given. Review of Resident 13's physician orders failed to reveal wound care orders for Resident 13's right buttock pressure ulcer. During an interview on June 11, 2025 at 1:53 PM, with the Nursing Home Administrator and Director of Nursing (DON), the DON revealed the wound care recommendations for Resident 13's right buttock pressure ulcer were missed and that Resident 13 now has wound care orders. The DON stated it was the expectation of the facility that recommendations from the wound care provider be entered as treatment orders. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12 (d)(1)(5) Nursing services 395647 Page 7 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on review of policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper urostomy care for one of one resident reviewed (Resident 4). Findings include: Review of facility policy, titled Colostomy/Ileostomy Care #066, with revised date of July 2015, and a last review date of June 18, 2024, revealed The following information should be recorded in the resident ' s medical record: 1. The date and time the colostomy/ileostomy care was provided. 2. The name and title of the individual(s) who provided the colostomy/ileostomy care. (The above information is generally documented in the Treatment Record.) 3. Any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation of skin. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken; and 6. The signature and title of the person recording the data. Review of Resident 4's clinical record revealed diagnoses that included neuromuscular disorder of the bladder and urostomy (artificial opening of the urinary tract on the abdomen). During an interview with Resident 4 on June 10, 2025, at 9:57 AM, Resident 4 indicated that she has a urostomy, that she provides her own urostomy care, and is comfortable doing so. Review of Resident 4's physician orders revealed an order for right urostomy: diagnosis of neurogenic bladder dated December 31, 2024. Further review of the physician orders failed to reveal any order for urostomy care. Review of Resident 4's care plan revealed a care plan focus for urostomy care, and interventions included care as ordered by my physician, skin nurse or charge nurse, with a revised date of January 25, 2019. Review of Resident 4's treatment administration records revealed that there was no documentation regarding urostomy care after March 23, 2025. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on June 12, 2025, at 1:52 PM, the DON confirmed that Resident 4 performs her own urostomy care and will either tell staff that she needs supplies or orders them herself because Resident 4 wants to maintain as much independence as possible. The DON further confirmed that there should be an order for urostomy care to include more details and that the urostomy care provision should be documented in Resident 4's clinical record. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 395647 Page 8 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to inform the dietician or physician of the non-availability of an ordered nutritional supplement for two of two residents reviewed for nutrition(Residents 31 and 39). Residents Affected - Some Findings include: Review of the clinical record for Resident 31 revealed diagnoses that included diabetes mellitus (body has trouble controlling blood sugar and using it for energy) and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). A review of the clinical record revealed that Resident 31 weighed 115.8 pounds on February 4, 2025, and on May 11, 2025, the Resident weighed 113.2 pounds, which is a -2.25 % pound weight loss over the 3 months. A review of the physician orders for Resident 31 revealed an order for Magic Cup (a nutritional supplement) twice a day beginning April 8, 2025. Progress notes dated April 27, 28, and 29, 2025, revealed that the Magic Cup was not available to be provided during the lunch or dinner meals as ordered due to being back ordered. A progress note dated May 6, 2025, at 4:00 PM, indicated the staff was unable to locate the Magic Cup. There was no documentation that the physician or dietician was notified of the unavailability of Magic Cup. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 12, 2025, at 1:50 PM, the NHA indicated that the Magic Cup was on back order in April. The DON confirmed that nursing staff should have notified the dietician and/or Resident 31's physician that the Magic Cup was not available and to seek for further guidance. Review of Resident 39's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) and stage 4 pressure injury (an injury resulting from pressure that extends below the subcutaneous fat into deep tissues, including muscle, tendons, ligaments, cartilage or bone). Review of Resident 39's clinical record revealed an order for Magic two times a day between meals for a low body mass index (BMI- a measure of body fat based on height and weight), with an original order date of April 17, 2025. Review of Resident 39's April Medication Administration Record and accompanying progress notes revealed the following: April 27, 2025, at 11:37 AM, the magic cup was not available; April 27, 2025, at 7:03 PM, the magic cup was not available; 395647 Page 9 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0692 April 28, 2025, at 12:57 PM, the magic cup was not available and Ensure was given; Level of Harm - Minimal harm or potential for actual harm April 29, 2025, at 12:50 PM, the magic cup was not available and Ensure was given; Residents Affected - Some April 29, 2025, at 6:30 PM, the magic cup was not available and the Resident 39 did not want anything else; and April 30, 2025, at 1:23 PM, the magic cup was not available. In addition, on April 28, 2025, at 7:00 PM, Resident 39 was documented as receiving the magic cup. Review of facility documentation provided revealed that magic cups were ordered on April 27, 2025, and were delivered to the facility on April 29, 2025. During a staff interview with the NHA and DON on June 12, 2025, at 1:50 PM, the NHA indicated that the magic cup had been on back order. The DON confirmed that nursing staff should have notified the dietician and/or Resident 39's physician that the magic cup was not available and to seek for further guidance. She also confirmed that staff had provided ensure as a substitute but agreed that nursing staff did not have an order to do so. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395647 Page 10 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

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 observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure controlled substances were contained in a double locked compartment for one of one medication rooms observed (Arlington Hall), and failed to ensure appropriate labeling of medications when opened for two of two medication carts observed (2-AE and 2-A hall). Findings include: Review of facility policy, titled Accountability of Medications and Controlled Substances, last reviewed July 18, 2024, read, in part, d. Medication storage areas remain locked when not in use. Controlled substances are double locked in the medication carts. Emergency controlled substances are also double locked. Review of facility policy, titled Multi-Dose Medication Storage, last reviewed July 18, 2024, read, in part, 1. All multi-dose vials are to be dated when opened . Observation of the medication storage room refrigerate in the Arlington hall on June 11, 2025 at 9:17 AM, with Employee 3, revealed one 30 milliliter bottle of lorazepam laying on top of the non-removable lock box. Further observation of the refrigerator lock box revealed the box was not locked and contained seven vials of lorazepam. An interview on June 11, 2025, at 9:17 AM, with Employee 3 revealed the lorazepam should be stored in the box and the box should be locked. Observation of the medication cart on 2-AE on June 11, 2025 at 9:04 AM, with Employee 3 present, revealed an open bottle of acetaminophen tablets with no open date and an open bottle of cranberry tablets with no open date. An interview on June 11, 2025 at 9:04 AM, with Employee 3, revealed medications are to be dated when opened. Observation of the medication cart on 2-A on June 11, 2025 at 9:30 AM, with Employee 2 present, revealed an open bottle of calcium 600 + vitamin D tablets with no open date, an open bottle of multi vitamins with no open date, and an open container of prosource powder with no open date. During an interview on June 12, 2025 at 1:51 AM, with the Nursing Home Administrator and the Director of Nursing (DON), the DON revealed with was the expectation of the facility that medication be dated when opened. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12 (d)(1)(5) Nursing services 395647 Page 11 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations and resident and staff interviews, it was determined that the facility failed to provide food that was palatable in accordance with resident preference for one of 15 residents observed in the dining room (Resident 9); and failed to provide food in accordance with selected menu items for one of 15 residents observed in the dining room (Resident 11). Residents Affected - Few Findings include: Observations of Resident 9's lunch meal on June 9, 2025, revealed that she didn't eat the piece of chicken on her tray. Resident did mark her meal ticket for plain chicken (no marinara sauce on top) and to prepare well done. The chicken was white with no grill marks on one side and two streaks of grill markings that could barely be seen on the opposite side. During an interview with the Resident on June 9, 2025, at approximately 12:30 PM, Resident 9 stated that she was unable to eat the chicken the way it was prepared, describing it as not palatable (texture and appearance) and not cooked enough. During an interview with Employee 1 (Director of Dining Services) on June 9, 2025, at approximately 1:00 PM, he was asked how the chicken was prepared because of the appearance. Employee 1 stated that it is thawed, steamed, and tossed on the grill. Employee 1 agreed that the chicken was not prepared based on Resident 9's request, and stated that if prepared well done, it would be too dry. Observation of Resident 11 in dining room on June 9, 2025, at 12:33 PM, revealed that on her meal ticket had been marked for her to receive chicken and penne pasta with red sauce. Resident 11 was observed to have chicken and mashed potatoes with a yellow colored gravy. During an immediate staff interview with the nursing team member assisting Resident 11 regarding the lack of pasta, the team member indicated It must have been missed. It has been a hectic day. During a staff interview with Employee 1 on June 9, 2025, at 12:43 PM, Employee 1 indicated that nursing staff selects Resident 11's food items since she is incapable. He further indicated that dietary staff served Resident 11 mashed potatoes because she generally eats them very well. He did confirm that they had the pasta with red sauce available and that it should have been served to her since it was selected on the meal ticket. During continued observation of the dining room on June 9, 2025, until 12:55 PM, revealed that Resident 11 was not served the penne pasta with red sauce. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on June 11, 2025, at 2:25 PM, the NHA indicated that since nursing staff had marked the ticket it was not necessarily Resident 11's preference to receive the pasta, but did agree that since it was available it should have been served. 28 Pa. code 211.6 Dietary Services 395647 Page 12 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 policy review, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen, walk in freezer, and two of two pantries. Findings include: Review of facility policy, titled Labeling and Dating, last reviewed July 18, 2024, revealed the following: 3. All prepared menu items will be dated (m/d) in compliance of a 3 day 'Use by' date. Day 1 is counted as the day of prep. The item is discarded at the end of day 3 . 4. Any unopened food or beverage item will be discarded by the manufacturer labeled expiration date. Examples of what is considered an expiration date can be preceded by, but are not limited to, Use By, Fresh Through, Sell By, etc. In a health care setting consider these expiration terms. Observations made in the main kitchen on June 9, 2025, at 9:37 AM, revealed an open bag of chips with no open date, an open bag of bread with no open date, an open bag of rolls with no open date, and a bowl containing a green flaky substance with no label or date. Observation of reach in refrigerator #1 in the main kitchen revealed one open container of cool whip with no open date. Observation of reach in refrigerator #2 in the main kitchen revealed: one open container of turkey base with an open date of April 17; one open container of seafood base with an open date of May 25; one open container of basil pesto with an open date of May 7 and an expiration date of June 7, 2025; one open container of cocktail sauce with a use by date of June 6, 2025; one open bottle of mayonnaise with an expiration date of November 30, 2024; one container of cut lemons with a use by date of June 6; one container of cut lemons with a use by date of June 7; one open bottle of lemon juice with no open date; and one open bottle of chocolate syrup with no open date. Further observation of the main kitchen revealed two multi use ovens with a heavy amount of white staining on the table under the ovens as well as a heavy amount of water damage to the wall behind the ice machine at the water line connection. An interview with Employee 1 on June 9, 2025, at 10:15 AM, revealed all open and prepared foods should be dated with an open or prepared date and discarded by the expiration dates. Employee 1 revealed the multi-use ovens and tables they sit on are cleaned every evening but hard water had caused white staining on the surfaces. Employee 1 also revealed there had been an on and off issue with the water line to the ice machine leaking and that a maintenance request had been entered. Observation of the walk in freezer on June 9, 2025, at 10:30 AM, revealed a metal shelving unit with multiple shelves having a brownish red discoloration and a large amount of greenish/brown substance on the shelves and pooled on the floor beneath the shelves. Interview with Employee 1 on June 9, 2025, at 10:30 AM, revealed there is not a cleaning schedule for the walk in freezer. 395647 Page 13 of 14 395647 06/12/2025 Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation of the 2A hall pantry on June 9, 2025, at 11:30 AM, revealed one open container of Thick it with an open date of May 2025 and expiration date of June 2024. Observation of the [NAME] pantry on June 9, 2025, at 11:35 AM, revealed four packets of thicken coffee with expiration dates of March 29, 2025, and an open bag with frozen chocolate bananas with no open date. During an interview on June 12, 2025 at 1:52 PM, with the Nursing Home Administrator (NHA) and Director of Nursing, the NHA revealed it was the expectation of the facility that food be dated when opened or prepared and that expired foods be discarded. The NHA also stated it was the facility's expectation that equipment be maintained and clean. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.6(f) Dietary services 395647 Page 14 of 14