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. (continued on next page) 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 6 Event ID: 396111 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 396111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Utz Terrace 2100 Utz Terrace Hanover, PA 17331 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)