F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, review of facility policy, clinical record review, resident and staff interviews, it was determined
that the facility failed to provide appropriate Activity of Daily Living (ADL) for two of 6 residents reviewed
who were unable to carryout ADL care independently. (Resident R1 & R3)
Residents Affected - Few
Findings include:
Review of MDS (Minimum Data Set-assessment of resident care need) for Resident R1 dated April 2,
2024, revealed that the resident was dependent on the staff for showers, transfers, and toileting. MDS also
revealed that the resident had a BIMS (Brief Interview for Mental status) score of 8 which indicated that the
resident's cognitive status for daily decision making was moderately impaired.
Clinical record indicated that Resident R1 was scheduled for showers on Wednesday and Saturday from
7-3 shift.
On June 13, 2024, at 2:35 p.m. a review of Shower Task Performance Documentation with the Director of
Nursing revealed and confirmed that Resident R1 was not given showers on Wednesdays May 8, 15, 22,
2024 and June 5, 2024, as per her schedule.
Review of Resident R3's clinical record review indicated that Resident R6 was admitted to the facility on
[DATE].
Clinical record indicated that Resident R3 was scheduled for showers/bed baths on Tuesday and Fridays.
On June 13, 2024, at 10:29 a.m. an interview and observation held with Resident R3 who was in lying in
bed mid-size facial hair, long hair, and long nails. The long hair looked greasy and dead white flakes on the
top of his/her hair. Resident when questioned if he/she desires to cut his hair, facial hair, and nails. Resident
R3 responded yes but I'm unable to do it myself. Resident R3 prefers bed baths over shower as he/she has
colostomy bag. This observation was confirmed by License Nurse, Employee E5.
28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 211.12(d)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
395922
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
395922
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Artman Lutheran Home
250 North Bethlehem Pike
Ambler, PA 19002
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policies, clinical record review and interviews with staff, it was determined that the facility
failed to ensure that physician orders were followed related to toileting program, tubi-grips, gel cushion to
wheelchair, for one resident of six residents reviewed. (Resident R1)
Residents Affected - Few
Findings include:
Review of facility policy, Medication Order undated, revealed, it is the policy of [NAME] Lutheran to establish
uniform guidelines in the receiving and recording of medication orders. To ensure safe and effective use of
medications and that medication information on residents is captured, used and communicated.
Review of active physician order for Resident R1 revealed an order dated December 11, 2023 toileting
schedule: Take resident to the bathroom/offer toileting resident at around 8:00 a.m., 11:00 a.m., 2:00 p.m.,
5:00 pm, 8:00 p.m. check and change as need while asleep. Order dated May 1, 2023 tubi-grips to bilateral
lover extremities place on in am and remove at bedtime. On November 3, 2022, to gel cushion to
wheelchair check placement and integrity every shift.
A review of the Task Documentation for Toilet Use from May 1, 2024 -June 12, 2024, the following dates did
not document 11:00 am toileting attempt:
May 1, 2,3, 4,6,7,8,9,10,11,12,13,14,15,16,17,18,19,21,22,23,24,25,26,27,28,29,30,31, 2024
June 2, 3,4,5,6,7, 8, 9, 10, 11, 12, 2024
On June 13, 2024, at 10:39 a.m. to 11:15 a.m. interview and observations were completed in the living
room of Resident R1 participating in activities but was not taken to the complete a toilet program per the
physician order at 11am. Further observations were completed during the same day from 12:22 p.m. to
2:05 p.m. with Resident R1 who as having lunch and then transitioned to the living room for activities. There
was no implementation of toileting program at 2pm.
On June 13, 2024, at 12:37 p.m. observations made with Rehabilitation Director, Employee E13 that
Resident R1 was sitting in her wheelchair eating lunch and had wheelchair foot rest heel loops/strips which
would prevent the resident's heel to slide backwards was broken off on the right side. Resident R6 was
sitting at the same dining table with Resident R1 and had a foot rest loop broken off as well on the left side.
Employee E13 replaced it with new [NAME] and reported that there was no need for the [NAME] loops to
be attached.
On June 13, 2024, at 1:05 p.m. observation was taken place that Resident R1 was sitting in the dining room
with no tubi-grips per the physician order. License Nurse, Employee E5 confirmed the observation and
reported I must have forgot. Employee E5 went into Resident R1's room to locate tubi-grips and there was
nonavailable. Employee E5 stated I will have to order it.
28 Pa. Code 211.10(c) Resident care policies
28 Pa Code 211.12(d)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395922
If continuation sheet
Page 2 of 2
