Health inspection·May 25, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 13 residents reviewed (Resident 37). Residents Affected - Few Findings Include: Review of Resident 37's clinical record revealed diagnosis that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 37's MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated April 20, 2023, revealed that Section O0100 Special Treatments, Procedures, and Programs, part K. Hospice care, was marked No, indicating that Resident 37 had not received Hospice services during the 14 day look back period. Review of physician's orders in Resident 37's electronic medical record revealed a physician's order from April 12, 2023, revealed that Resident 37 was discharged from Hospice services as of April 12, 2023. Interview with the Director of Nursing on May 24, 2023, at 10:00 AM, revealed that she agreed that Resident 37's status of receiving Hospice services should have been reflected on the MDS dated [DATE]. 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services Page 1 of 4 396111 396111 05/25/2023 Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure the attending physician or prescriber responded to medication regimen reviews, completed by a consultant pharmacist, in a timely manner for two of 13 residents reviewed (Residents 6 and 26). Findings include: Review of facility policy, titled Drug Regimen Review Monthly Admission/Readmission, revised February 2023, revealed in step 4. that when the Consultant Pharmacist's medication regimen review is completed, it is provided to the attending physician/prescriber- the physician must review and act or respond within 30 days. Review of Resident 6's clinical record revealed diagnoses that included chronic osteomyelitis (a bone infection that doesn't go away with treatments) and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). Review of Medication Regiment Review form for Resident 6 dated December 12, 2022, revealed that a review was completed by the consultant pharmacist and recommendations were made. Further review revealed that no physician or prescriber responded to the report until February 23, 2023; 73 days later. Review of Resident 26's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder) and diabetes (a metabolic disease, involving inappropriately elevated blood glucose levels). Review of Medication Regiment Review form for Resident 26 dated December 12, 2022, revealed that a review was completed by the consultant pharmacist and recommendations were made. Further review revealed that no physician or prescriber responded to the report until February 23, 2023; 73 days later. Interview with the Director of Nursing on May 24, 2023, at 1:30 PM, revealed that the physician did not respond to Resident 6's and 26's medication regiment reviews in a timely manner because there was a problem with the process, which they are working on fixing. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(c) Resident care policies 396111 Page 2 of 4 396111 05/25/2023 Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on document review and staff interview, it was determined that the facility failed to ensure the quality assessment and assurance committee consists of the minimum required members for three of three quarterly meeting sign-in documents reviewed (October 2022, January 2023, and April 2023). Residents Affected - Some Findings Include: Review of the facility's attendance record for the months of October 2022, January 2023, and April 2023 revealed no record of participation by the facility's Infection Preventionist. An interview with the Nursing Home Administrator on May 23, 2023, at 12:58 PM, revealed the facility had no qualified Infection Preventionist on staff at that time and during those meetings. 28 Pa. Code 201.14 (a) Responsibility of licensee 396111 Page 3 of 4 396111 05/25/2023 Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interviews, employee training documents, and regulations, it was determined that the facility failed to have an Infection Preventionist (IP) that completed the approved program for specialized training in infection prevention and control to obtain final certificate with 19.3 CEU (continuing education units). Findings include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(4) states, The facility must designate one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's IPCP (Infection Prevention Control Program) that have completed specialized training in infection prevention and control. Completion of the Centers for Disease and Control (CDC) Train Program requires passing the examination and then eligibility to obtain the official certificate of completion with 19.3 CEUs being completed. Additionally, the individual must work a minimum of part-time within the facility. Employee 6 (Registered Nurse) assumed the role as IP at the facility on January 1, 2023. The previous IP resigned from the facility on September 9, 2022. During an interview with the Director of Nursing (DON) on May 22, 2023, at 1:50 PM, Employee 6's IP certificate of completion by CDC Train credentials were requested that showed the 19.3 CEUs were completed. The DON stated Employee 6 had a deadline of 30 days to repeat the test and complete the post-test evaluation, and that deadline was not met by Employee 6. During an interview with the Nursing Home Administrator (NHA) on April 13, 2023, NHA stated the current IP is unable to provide a certificate of completion of the program for specialized training in infection prevention and control as specified in the manual. The facility was also unable to provide proof that the program is supported by CDC or CMS as an approved program for IPs. 28 Pa. Code 201.18(b)(2) Management 396111 Page 4 of 4