Health inspection·May 16, 2024

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 Based on observation, clinical record review and staff interview it was determined that the facility failed to ensure a resident unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for one of fifteen residents reviewed (Resident 12). Residents Affected - Few Findings Include: Activities of Daily Living (ADL's- a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, other personal hygiene and mobility). Review of Resident 12's clinical record revealed diagnoses that included hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and cerebral vascular accident (a stroke, also referred to as a cerebral vascular accident (CVA) or a brain attack, is an interruption in the flow of blood to cells in the brain). An observation and interview with Resident 12, on May 14, 2024, at 9:11 AM revealed the resident in the room and found to have significant facial hair. The facial hair was most prominently observed on the upper lip and chin areas. The interview with Resident 12 revealed feeling depressed regarding the amount of facial hair and stated she would accept staff assistance with removing the hair from her face. Review of Resident 12's interdisciplinary plan of care revealed impaired function with activities of daily living due to medical diagnoses. However, no documentation regarding Resident 12's refusal of personal hygiene care, including shaving. An interview with the Director of Nursing (DON), on May 14, 2024, at 10:01 AM revealed Resident 12 is believed to have a condition that promotes excessive hair growth. The interview also revealed Resident 12 is documented to have last been shaved by staff on April 28, 2024. An additional interview with the DON, on May 15, 2024, at 2:50 PM revealed Resident 12 was reapproached, and staff assisted the resident with shaving her facial hair. A final interview with the DON, on May 16, 2024, at approximately 11:30 AM revealed the facility had no additional information to provide regarding the prominent amount of facial hair found during the interview with Resident 12 on May 14, 2024. 28 Pa. Code 211.12 (d) (5) Nursing services Page 1 of 2 396111 396111 05/16/2024 Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review observations, and staff interviews, it was determined that the facility failed to provide respiratory services for two of fifteen residents reviewed (Resident 10 and 28). Residents Affected - Few Findings include: Review of facility provided policy titled, Oxygen Administration, reviewed March 2024, revealed that the humidifier bottle should be labeled with the date and time changed. Observation of Resident 10 on May 13, 2024, at 10:06 AM, revealed the resident sitting in their bed. On the side of the bed was an oxygen concentrator and the oxygen concentrator humidification bottle was labeled that it was put into use on May 3, 2024. Review of Resident 10's clinical record revealed diagnoses that include diabetes mellitus (a group of diseases that result in too much sugar in the blood (high blood glucose)) and respiratory failure (when the lungs can't release enough oxygen into your blood). Review of Resident 10's physician's orders on May 16, 2024, revealed an order to change oxygen equipment and clean the oxygen concentrator filter every week. Review of Resident 10's Medication Administration Record for the month of May 2024, revealed that this should have been completed on May 9, 2024. Observation of Resident 28 on May 13, 2024, at 10:34 AM, revealed the resident sitting in a lounge chair beside their bed. Beside the chair was an oxygen concentrator and the oxygen concentrator humidification bottle labeled that it was put into use on May 3, 2024. Review of Resident 28's clinical record revealed diagnoses that include atrial fibrillation (a type of heart arrhythmia that causes the upper chambers of the heart to beat irregularly and quickly) and congestive heart failure (is a complex clinical syndrome characterized by inefficient myocardial performance, resulting in compromised blood supply to the body). Review of Resident 28's physician's orders on May 14, 2024, revealed an order to change and date oxygen equipment (tubing and humidifier bottle) and clean the oxygen concentrator filter every week. Review of Resident 28's Medication Administration Record for the month of May 2024, revealed that this should have been completed on May 9, 2024. During an interview with the Director of Nursing on May 16, 2024, at 10:35 AM, revealed that Resident 10 and 28 required supplemental oxygen and their humidification bottles should have been changed weekly as ordered by the physician. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. 396111 Page 2 of 2