Health inspection·April 30, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm 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 observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 12 residents reviewed (Residents 14 and 26). Residents Affected - Few Findings Include: Review of Resident 14's clinical record revealed diagnoses that included atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart [atria] beat irregularly and often too rapidly) and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood effectively). Review of Resident 14's physician orders revealed an order for Xarelto (anticoagulant medication) 15 mg in the morning for atrial fibrillation, with a start date of February 9, 2023. Review of Resident 14's care plan failed to reveal a care plan with a focus area related to anticoagulant medication. Interview with the Director of Nursing (DON) on April 29, 2025, at 10:55 AM, revealed they thought an adequate care plan had been enacted into Resident 14's care plan. Review of Resident 26's clinical record revealed diagnoses that included stage 3 pressure ulcer of the sacrum (a deep wound that extends through the skin into the fatty tissue below, but does not expose muscle or bone, located on the sacrum) and stage 3 pressure ulcer of the back (a stage 3 pressure ulcer located on the back). Review of a wound evaluation dated March 5, 2025, revealed the discovery of a stage 3 pressure wound on Resident 26's sacrum. Review of a wound evaluation dated April 9, 2025, revealed the discovery of a stage 3 pressure wound on Resident 26's left upper back, the evaluation also revealed that the stage 3 pressure wound on the sacrum was still present. Review of the most recently completed wound evaluation dated April 23, 2025, revealed that both stage 3 pressure wound on Resident 26's back and sacrum were still present. Observation of a dressing change on April 29, 2025, at 9:45 AM, revealed that Resident 26 still had stage 3 pressure wounds on their back and sacrum. Page 1 of 6 396111 396111 04/30/2025 Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331

F 0657 Level of Harm - Minimal harm or potential for actual harm Review of Resident 26's care plan failed to reveal a care plan with a focus area related to pressure wounds or skin care. Interview with the DON on April 30, 2025, at 10:30 AM, revealed that the care plan for Resident 26's ongoing skin care had been inadvertently removed. Residents Affected - Few 28 Pa. Code 211.12(d)(5) Nursing services 396111 Page 2 of 6 396111 04/30/2025 Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of select food service committee meeting minutes, resident and staff interviews, and observations, it was determined that the facility failed to produce sufficient food to support resident requests based on the posted menu for one meal observed. Findings include: Review of Skilled Care Food Committee Meeting minutes dated April 8th, 2025, residents revealed that food items run out and they don't get what is on the menu. During an interview with Resident 1 on April 28, 2025, 11:00 AM, the Resident revealed that she doesn't like the taste of the food and that she would complete a selection menu, but she does not always get what she selected because they ran out of food. Review of Resident 1's daughter's grievance/concern submitted to the facility on December 9, 2024, read, in part, that her mother doesn't receive the menu items she selects because the facility runs out of food, and the food she gets is frequently inedible. Observation of the posted menu outside of the dining room on April 29, 2025, at 12:00 PM, revealed the lunch menu was citrus roasted pork, baked sweet potato, broccoli, and butterscotch pudding, and the alternate entree was vegetable Alfredo. Additional observation on April 29, 2025, at 1:06 PM, revealed Employee 2 altered the resident menu selections on Residents' 14, 22, 24, 187, and 188's meal tickets. Employee 2 confirmed that they ran out of sweet potato, which was the starch on the posted menu and, therefore, they substituted mashed potatoes. During an interview with Employee 3 on April 29, 2025, at 1:20 PM, it was revealed that production sheets aren't utilized. It was also revealed that residents choose their menu selection at time of service. During an interview with the Nursing Home Administrator on April 29, 2025, at 2:00 PM, it was revealed that sufficient food should be prepared to serve the posted menu. Pa code 211.6 - Dietary Services 396111 Page 3 of 6 396111 04/30/2025 Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, observation, completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed (April 29, 2025, lunch meal). Residents Affected - Few Findings include: During an interview with Resident 1 on April 28, 2025, at 11:00 AM it was revealed that she doesn't like the taste of the food, and the hot food is often cold. Resident 1 stated that she usually eats in her room for breakfast and lunch and will go to the dining room for dinner. Review of Resident 1's daughter's grievance/concern submitted to the facility on December 9, 2024, read, in part, that her mother doesn't receive the menu items she selects because the facility runs out of food, and the food she gets is frequently inedible. During an interview with Resident 33 during the initial pool process on April 28, 2025, it was revealed he doesn't like the taste of the food, and the hot food it is often cold. Review of facility form, Tray Line Test Tray Audit, revised January 2020, read, in part, test tray standard for hot entree and vegetable is greater than or equal to 135 degrees Fahrenheit. Test tray is also evaluated for adequate flavor and texture of the food. A test tray completed on April 29, 2025, at 1:17 PM revealed adequate portions size, the vegetable alfredo wasn't palatable for taste it was bland, the texture of the broccoli was over cooked/very soft, and the vegetable alfredo and broccoli weren't palatable for temperature. The test tray was placed on a meal cart to be delivered with room trays; 18 minutes had elapsed between the time the test tray was prepared from the service line and presented for evaluation. Employee 3, [NAME] President of Operations for the consultant Food Service Company, took temperatures of the food items at the time the test tray was served for evaluation. The following were the recorded highest temperatures: Vegetable alfredo- 133 degrees Fahrenheit Baked sweet potato- 143 degrees Fahrenheit Broccoli- 139 degrees Fahrenheit Butterscotch pudding - room temp Iced tea- 46 degrees Fahrenheit Coffee- 137 degrees Fahrenheit During an interview with Employee 3, [NAME] President of Operations for the consultant Food Service Company, on April 29, 2025, at 1:20 PM it was revealed that the temperature of the vegetarian alfredo and the broccoli weren't to company standards. It was acknowledged that it took a while to 396111 Page 4 of 6 396111 04/30/2025 Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331

F 0804 assemble the room trays and therefore the tray sat longer than expected. Level of Harm - Minimal harm or potential for actual harm During an interview with the Nursing Home Administrator on April 29, 2025, at 2:00 PM it was revealed that foods should be served at adequate temperatures and should be palatable. Residents Affected - Few 28 Pa. Code 201.14. Responsibility of licensee 28 Pa code 211.6 - Dietary Services 396111 Page 5 of 6 396111 04/30/2025 Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the main kitchen walk-in freezer and in the kitchenette food temperature log. Findings include: Review of facility policy, Labeling and Dating, revised May 14, 2018, read, in part, all food items must be labeled with either a manufacturer label or handwritten label. Upon receipt all food items, must be dated with receiving date. Review of facility policy, Food Service Temperature Logs, last reviewed March 2010, read, in part, food temperatures must be recorded on all hot and cold foods prior to meal service using the Temperature and Meal Evaluation Form. Observation in the walk-in freezer in the main kitchen on April 28, 2025, at 9:32 AM, revealed there were three packages of naan bread out of the cardboard case and not date marked. During an interview with the Employee 4 (General Manager) on April 28, 2025, at 9:32 AM, it was revealed that the packages should've been date marked with a received date or left in the case which should be date marked. Observed of food temperature logs in the Kitchenette on April 28, 2025, at 9:44 AM, revealed eight dinner meals over the past 27 days that the food temperatures weren't recorded. During an interview with Employee 4 on April 28, 2025, at 9:44 AM, it was revealed that the temperature log should be completed for all meals. During an interview with the Nursing Home Administrator on April 29, 2025, at 2:00 PM, it was revealed that all items should be labeled with a received date, and that food temperatures should be recorded for each meal. 28 Pa code 211.6 - Dietary Services 396111 Page 6 of 6