Inspection visit

Health inspectionSeptember 14, 2023

SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGECMS #3961469 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to implement their established procedures for investigation and protection of residents related in response to potential abuse of two of 12 residents reviewed (Resident 3 and 8). Residents Affected - Few Findings include: Review of facility policy, titled Risk Management Incident/Accident Reporting Standard last revised November 28, 2017, revealed, Each Spiritrust Lutheran Skilled Care Community identifies potential safety hazards, identifies residents at risk for accidents and/or falls and adequately plans care and implements procedures to prevent accidents .Completing a thorough investigation into the probable causes of the incident/accident, Planning appropriate interventions to prevent reoccurrence of incidents/accidents, On-going review and revision of Plan of Care interventions as necessary .An incident is defined as any unusual event such as falls, skin tears, bruises, injuries of unknown origin, Following the identified occurrence, and Incident/Accident Report is initiated immediately in the EHR (electronic health record) in the 'Risk Management' section .Abuse investigations and unknown origin investigations require signed witness statements .witnesses are interviewed, verbal statement documented .information dictated verified with witness by licensed nurses/designee prior to saving the statement in EHR, the information requested in the EHR is completed in its entirety. Review of Resident 3's clinical record revealed diagnoses that included Repeated falls, dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and difficulty walking. Review of Resident 3's clinical record revealed a nursing note on August 30, 2023, at 10:46 AM, that stated [Nurse Aid] called this nurse into resident's room when she was assisting him in getting dressed. Skin tear noted to upper back of L[eft] arm. Area is 1cm [centimeter-unit of measure] X 1cm. Resident unsure of how he obtained it. Cleansed area with NSS [normal saline solution], applied bacitracin & DSD [dry sterile dressing]. Resident pulling arm away when trying to look at it & when dressing it. Called & left voicemail with POA [Power of Attorney- legal representative] to call back for update. RN [Registered Nurse] notified. During email correspondence with the Nursing Home Administrator (NHA) on September 12, 2023, at 12:07 PM, the surveyor inquired about an investigation related to Resident 3's skin tear discovered on August 30, 2023. Interview with Employee 1 (Clinical Excellence Nurse) on September 13, 2023, at 10:27 AM, revealed she does not have any information to provide that an investigation was conducted, and she would (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 17 Event ID: 396146 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0607 expect a thorough investigation to be completed per the facility policy. Level of Harm - Minimal harm or potential for actual harm During an interview with the NHA on September 14, 2023, at 11:03 AM, the surveyor revealed the concern with the facility's failure to follow established procedures for investigation and protection of residents related in response to potential abuse. The NHA revealed she would expect a thorough investigation to be completed per the facility policy. Residents Affected - Few Review of Resident 3's clinical record revealed diagnoses that included Abnormal posture, dementia, and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Review of Resident 3's clinical record revealed an incident note on July 31, 2023, at 8:57 PM, that stated, Description of Incident/Accident: Notified by [Nurse Aide] of bruise to R[ight] outer elbow. Resident Comments/Cognitive Status: [Resident 8] states that she 'woke up with it one morning' and 'didn't know where it came from' Evaluation/Injury including measurements of wounds if applicable: Bruise observed on R[ight] outer elbow measuring 3cm X 2cm. No complaints of of pain. Further review of the incident note on July 31, 2023, at 8:57 PM, revealed the section of the note was left blank for Immediate intervention for prevention, Care/Treatment Provided. During email correspondence with the NHA on September 12, 2023, at 12:07 PM, the surveyor inquired about an investigation related to Resident 8's bruise discovered on July 31, 2023. Review of Resident 8's care plan revealed no new interventions were added related to the discovered bruise after July 31, 2023. Interview with Employee 1 on September 13, 2023, at 10:27 AM, revealed she does not have any information to provide that an investigation was conducted, and she would expect a thorough investigation to be completed per the facility policy. During an interview with the NHA on September 14, 2023, at 11:03 AM, the surveyor revealed the concern with the facility's failure to follow established procedures for investigation and protection of residents related in response to potential abuse. The NHA revealed she would expect a thorough investigation to be completed per the facility policy. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 2 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 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 interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for four of 15 residents reviewed (Resident 7, 21, 34, and 41) Residents Affected - Some Findings Include: Review of Resident 7's clinical record on September 11, 2023, at approximately 1:00 PM, revealed diagnoses that included stage 4 chronic kidney disease (severe decrease in the kidneys ability to filter toxins from the blood) and diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). Review of Resident 7's Minimum Data Set (MDS - Assessment tool utilized to identify a residents' physical, mental and psychosocial needs), including an admission MDS with an Assessment Reference Date (ARD) of February 7, 2023; a Significant Change MDS with an ARD of April 10, 2023; a Quarterly MDS from May 9, 2023; and a Quarterly MDS from August 9, 2023, revealed that Section N - Medications, subsection

N350 was coded to reflect that Resident 7 was receiving insulin injections during the assessment look-back period. Review of Resident 7's medications orders, including discontinued medications, since Resident 7's admission on [DATE], revealed that at no time was Resident 7 receiving insulin injections. During a staff interview on September 14, 2023, at approximately 11:20 AM, Corporate Quality Excellence Nurse confirmed that Resident 7 had not received insulin and that Resident 7's MDS assessments were coded incorrectly in regard to Section N350. Review of Resident 21's clinical record revealed diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dysphagia (difficulty swallowing), and hypertension (high blood pressure) Review of Resident 21's clinical record revealed a provider note dated June 7, 2023, that stated, Diagnostic Statement: Dementia in other diseases classified elsewhere, severe, with psychotic disturbance (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) .Dementia With Complications. Further review of Resident 21's clinical record revealed a provider note dated June 23, 2023, that stated, Diagnostic Statement: Dementia in other diseases classified elsewhere, severe, with psychotic disturbance .Dementia With Complications. Review of Resident 21's Significant Change Minimum Data Set with ARD of July 3, 2023, revealed, Section I: Active Diagnoses, subsection I4800. Non-Alzheimer's Dementia, was not assessed to indicate that Resident 41 had a diagnosis of dementia. Interview with Employee 1 (Clinical Excellence Nurse) on September 13, 2023, at 2:07 PM, revealed Resident 21's diagnosis of dementia was missed by Employee 2 (Registered Nurse Assessment Coordinator), and the assessment should have been coded to indicate Resident 21 has a diagnosis of dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 3 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the Nursing Home Administrator (NHA) on September 14, 2023, at 12:12 PM, revealed she would expect the Resident assessment to be coded accurately. Review of Resident 34's clinical record on September 11, 2023, at approximately 1:00 PM, revealed diagnoses including diabetes mellitus type II with hyperglycemia (when a person's blood sugar elevates to dangerous levels) and Major Depressive Disorder (ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life). Review of Resident 34's Quarterly MDS with an Assessment Reference Date of June 27, 2023, reveled that Section K - Swallowing/Nutritional Status, subsection K0300 was coded, No or unknown, for Weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. Review of Resident 34's clinical record revealed on December 6, 2022, Resident 34 weighed 191.6 pounds. On June 16, 2023, within the Assessment Reference Date of Resident 34's Quarterly MDS, Resident 34 weighed 168.4 pounds. This weight change indicated a 12.11 % loss. During an interview with Corporate Clinical Excellence Nurse, in the presence of the NHA, on September 13, 2023, at 2:15 PM, revealed it was the facility's expection that the Resident 34's MDS assessment would be coded correctly. Review of Resident 41's clinical record revealed diagnoses that included cerebral infarction (stroke damage to the brain from interruption of its blood supply), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and hypertension. Review of Resident 41's clinical record revealed a picture of Resident 41 wearing glasses. Review of Resident 41's clinical record revealed an inventory sheet upon admission on [DATE], noting Resident 41 came with four pairs of glasses. Review of Resident 41's 5 Day MDS with ARD of July 17, 2023, revealed under Section B - Hearing, Speech, and Vision, subsection B. 1000 Vision, Resident 41 was coded as Impaired, and subsection B. 1200 Corrective lenses Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision, Resident 41 was coded no to indicate she does not wear corrective lenses. Interview with Employee 1 on September 14, 2023, at 12:10 PM, revealed Resident 41 wore glasses and it should have been coded on her assessment. Interview with the NHA on September 14, 2023, at 12:12 PM, revealed she would expect the Resident assessment to be coded accurately. 28 Pa code 211.5(f) Clinical records 28 Pa code 211.12(d)(1)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 4 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 Based on clinical record review and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders for three of 12 resident's reviewed (Resident 21, 28, and 34). Residents Affected - Few Findings Include: Review of Resident 21's clinical record revealed diagnoses that included hypertension (high blood pressure), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), and dysphagia (difficulty swallowing). Review of Resident 21's physician orders revealed an order for: Amlodipine Besylate Oral Tablet 5 MG (milligrams- unit of measure), Give 5 mg by mouth two times a day related to Hypertension, Call MD (doctor) if B/P (blood pressure) >160 and if HR (heart rate) <50, with a start date of July 26, 2023. Review of Resident 21's MAR (Medication Administration Record- documentation for medication/treatment administered or monitored), revealed Resident 21's blood pressure measure was >160 on August 6, 7, 16, and 20, 2023; and September 1, 5, 6, and 13, 2023. Review of Resident 21's medical record revealed no documentation to indicate the doctor was notified of Resident 21's blood pressure measures being >160 on August 6, 7, 16, and 20, 2023, and September 1, 5, 6, and 13, 2023. Interview with the Director of Nursing (DON) on September 14, 2023, at 11:03 AM, revealed she could not find any information to indicate the doctor was notified of Resident 21's blood pressure measures being >160 on August 6, 7, 16, and 20, 2023; and September 1, 5, 6, and 13, 2023, and she would expect physician orders to be followed. Review of Resident 28's clinical record revealed diagnoses that included Multiple Sclerosis (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and hypertension. Review of Resident 28's clinical record revealed a documented, titled Physician Communication- Fax Orders/Telephone Orders, further review of the document revealed, Physician Orders: Consult with Neurologist to see if myzent (a medication for multiple sclerosis) is contributing to an increase in blood pressure, dated June 17, 2023, and signed by Employee 9 (Medical Director). Further review of Resident 28's clinical record revealed no documentation to indicate Resident 28 has seen a neurologist or that communication has been made with a neurologist related to the physician order after June 17, 2023. Interview with Employee 1 (Clinical Excellence Nurse) on September 14, 2023, at 12:12 PM, revealed she was unable to find any documentation to indicate Resident 28 has seen a neurologist since June 17, 2023, or that communication has been made with a neurologist related to the physician order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 5 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Nursing Home Administrator on September 14, 2023, at 12:15 PM, the surveyor revealed the concern with Resident 28's physician order not being followed. No further information was provided. Review of Resident 34's clinical record on September 11, 2023, at approximately 1:00 PM, revealed diagnoses that included type 2 diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should) with hyperglycemia (when a person's blood sugar elevates to dangerous levels) and Major Depressive Disorder. Review of Resident 34's physician orders revealed an order for skin inspection weekly as per skin integrity program on bath days, Tuesday daytime in the morning, and to document if skin impairment noted or not. Review of Resident 34's MAR revealed Employee 12 (Licensed Practical Nurse) documented no skin impairment was present on Tuesday September 5, 2023, at 7:30 AM, and Tuesday September 12, 2023, at 7:30 AM. Review of Resident 34's clinical record on September 12, 2023, at approximately 10:00 AM, revealed a document, titled Physician Communication - Fax Orders/Telephone Orders. Further review of the document revealed it contained, Problem: Redness/Excoriation vaginal area. Nystatin cream? dated September 6, 2023, at 11:45 PM, and signed by Employee 13 (Registered Nurse). It was it was observed that below the Problem area, the document contained a box for the physicians' response. Review of the physician response revealed an order for a new order of Diflucan (antifungal medication) 100 milligrams by mouth twice a day for two days, dated and signed by Employee 9 (attending physician) on September 7, 2023. Further review of Resident 34's clinical record revealed no documentation to indicate an initial assessment had been completed to record Resident 34's skin impairment. During a staff interview with Corporate Clinical Excellence Nurse on September 14, 2023, at 11:05 AM, it was revealed that the facility could not provide a documented assessment of Resident 34's redness and excoriation of the vaginal area. During the staff interview, Corporate Clinical Excellence Nurse revealed it was the facility's expectation that an assessment of Resident 34's rash would have been conducted and documented. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 6 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure care and services were provided to assess and maintain acceptable nutritional status for two of five residents reviewed for nutrition (residents 27 and 34). Residents Affected - Some Findings include: Review of facility policy, titled Weight Record Monitoring, last reviewed May 2023, revealed it stated, The physician and resident's responsible party are notified by the RD/designee of significant weight change (gain or loss) and of the IDT [interdisciplinary team] recommendations that would require further intervention/securing of new orders from the physician for the resident. Review of Resident 27's clinical record on September 12, 2023, at approximately 10:15 AM, revealed diagnoses that included hypertension (elevated/high blood pressure) and cerebella ataxia (disorder that results in poor muscle control which can affect speech, swallowing, eye movement, and extremity movement). Review of Resident 27's interdisciplinary progress notes revealed that on June 27, 2023, at 1:18 PM, Employee 3 (Registered Dietician) documented, .resident with current weight of 157lb [pounds], loss of 3.9lb in 30 days with a net significant loss of 26lb in 180 days (14.2%). Weight did stabilize from late April to May 2023, although trend now continues in June 2023. Resident continues on[sic] weekly weights to monitor, requested by 6/22/23 and by 6/29/23. Weight decline noted, despite resident consuming 76-100% of all meals .Recommend trailing additional entrée portion with meals, and offer additional (diet texture appropriate snack), between meals (AM, PM, HS). Consider geri-psych review for mood & review appropriateness of current medication. Will continue to follow weight trends and overall nutritional status. Review of a progress note documented on July 14, 2023, at 9:14 AM, by Employee 4 (Registered Dietician) revealed it stated, Net [weight] loss of 22 [pounds in] 180 days; 12%, significant [weight loss]. Intended increase of 4 [pounds] noted over past few weeks [related to] dietary interventions added due to weight loss .Weekly weights monitored . Review of Resident physician orders on September 12, 2023, at approximately 10:30 AM, revealed no order for Resident 27 to receive weekly weights. Review of Resident 27's comprehensive plan of care revealed that the care plan with the focus of: [Resident 27 has] a potential nutritional risk .[History] of weight loss & skin breakdown, included an intervention of, Obtain [Resident 27's] weight per weight standard. The intervention of weekly weights per Employee 3's progress note entered on June 27, 2023, was not included. Review of Resident 27's documented weights revealed that Resident 27 was not weighed during one week in June, 2023; four weeks during July, 2023; one week in August, 2023; and one week in September 2023. As of September 14, 2023, at 9:00 AM, Resident 27 did not have a documented weight since September 1, 2023. Review of Resident 27's clinical record on September 14, 2023, at approximately 11:30 AM, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 7 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0692 a physician's order for weekly weights that was entered at 10:43 AM on September 14, 2023. Level of Harm - Minimal harm or potential for actual harm During a staff interview on September 14, 2023, at approximately 12:00 PM, Corporate Clinical Excellence Nurse confirmed that Resident 27 did not have weekly weights ordered. During the interview, Corporate Clinical Excellence Nurse confirmed it was the facility's expectation that weekly weights should have been conducted on Resident 27 per the progress notes by Employee 3 and Employee 4 on June 27, 2023, and July 14, 2023, respectively. Residents Affected - Some Review of Resident 34's clinical record on September 11, 2023, at approximately 1:00 PM, revealed diagnoses that included type 2 diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should) with hyperglycemia (when a person's blood sugar elevate to dangerous levels) and Major Depressive Disorder (ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life). Review of Resident 34's clinical record, on September 12, 2023, revealed three significant weight losses (as defined as 5% or more weight loss in one month and/or 10% or more in six months) since admission to the facility. Review of Resident 34's documented weights revealed that on October 12, 2022, facility staff documented that Resident 34 was admitted weighing 203.3 pounds. Approximately six months later on April 5, 2023, Resident 34's documented weight was 164.7 pounds, which indicated an 18.99% loss. Review of Resident 34's interdisciplinary progress notes revealed that on April 3, 2023, Employee 3 documented a Nutrition note, which stated, .current weight 166[pounds], stable in 30 days with net significant loss of 37[pounds] in 180 days (18.2). Loss mostly [related to] improved fluid status after admission to this facility. Resident did have notable decline in oral intake from 3/9/23 to 3/29/23, which was supplemented with Glucerna 8oz daily [for] 30 days .No new recommendations at this time. Review of the clinical record revealed no documentation or evidence that Employee 3 notified the attending physician that Resident 34 had a significant weight loss during the prior 180 days. Review of weight documentation revealed that on August 10, 2023, Resident 34's documented weight was 176.8 pounds. On September 8, 2023, Resident 34's document weight was 165.4 pounds, which was a 6.45% loss within a 30 day period. Review of Resident 34's interdisciplinary progress notes on September 14, 2023, at approximately 12:15 PM, revealed no dietary note by a facility Registered Dietician regarding the significant weight loss of more than 5% between August 10, 2023, and September 8, 2023. Review of Resident 34's clinical record revealed no documentation that the physician was made aware of the significant weight losses identified as a result of weight assessments documented on April 5, 2023; June 16, 2023; and September 8, 2023. During a staff interview on September 14, 2023, at approximately 11:08 AM, Corporate Clinical Excellence Nurse was unable to provide documentation that the attending physician was notified of Resident 34's significant weight changes identified above, nor was Corporate Clinical Excellence Nurse able (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 8 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0692 Level of Harm - Minimal harm or potential for actual harm to provide documentation that the attending physician acknowledged and/or addressed the identified weight loss. 28 Pa code 211.10(a)(d) Resident care policies Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 9 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of menu extension forms, it was determined that the facility failed to provide food at appropriate portion sizes to meet the nutritional needs of residents for one of one meal observed (lunch meal, September 12, 2023). Findings include: Review of the menu diet extension sheet (menu items based on individual diets) for September, 12, 2023, lunch meal, revealed all diets should either be served a 4 ounce (unit of measure) portion of succotash or cream corn as the vegetable. Observation of lunch service on the [NAME] unit on September 12, 2023, at 12:37 PM, revealed Employee 5 used a plain plastic serving utensil to serve both the succotash and cream corn. During an interview with Employee 5 on September 12, 2023, at 12:39 PM, she revealed she is not sure how to tell what size portion the serving spoons were that she used to serve the succotash and cream corn. Observation of lunch service on the [NAME] unit on September 12, 2023, at 12:48 PM, revealed Employee 6 used a 3 oz scoop to serve the succotash vegetable. Interview with Employee 7 (Dietary Supervisor) on September 12, 2023, at 12:50 PM, revealed she would expect food to be served with the proper utensils for measured portions, and she plans to do education with the dietary staff. Interview with the Nursing Home Administrator on September 13, 2023, at 10:07 AM, revealed it is the facility's expectation that food is served at appropriate portion sizes specified by the menu extension sheets. Pa code 211.6(a)(b) - Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 10 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 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 Based on resident and staff interviews, completion of a meal test tray, and review of select facility documentation, it was determined that the facility failed to provide food at an appetizing temperature at one of one meals (lunch meal, September 13, 2023). Residents Affected - Few Findings include: Review of facility document, titled Test Tray Assessment last revised February, 2012, revealed that hot foods should be served at or above 130 degrees Fahrenheit (F - a unit of measure). During an interview with Resident 4 on September 13, 2023, at 11:04 AM, she revealed her food is often served cold. Review of June 2023 Resident Council Minutes (documentation of topics discussed during a monthly meeting), revealed concerns with food temperatures being too hot or too cold. A Test Tray was completed on September 13, 2023, at 12:32 PM, utilizing a lunch tray served in Arlington unit dining area after all meals were served to resident's on the unit. Test Tray included: baked cod, carrots, scalloped potatoes, ice cream, hot tea, and milk. Temperatures taken by Employee 3 (Registered Dietitian) revealed the carrots were 122 degrees F and scalloped potatoes were 121 degrees F. Interview with the Nursing Home Administrator on September 14, 2023, at 9:49 AM, revealed hot foods should be served at a temperature greater than 130 degrees Fahrenheit, as stated in the facility test tray documentation. 28 Pa. Code 211.6 (d) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 11 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen and two of three nourishment areas. Findings include: Review of facility policy, titled 3.4 Storing Food and Equipment, last revised March, 2020, revealed, Ensure all food items are labeled .Each label must contain the following information: Use-by date, date the product was prepared or opened .Generally, food should be discarded or used by the use-by date. The use-by date is the last date the manufacturer recommends use of the food and also may be referred to as the expiration date .cover, label and date all leftovers .keep all storage areas clean and dry. Observation in the main kitchen on September 11, 2023, at 9:28 AM, revealed a shelf with a container of cayenne pepper with a use-by date of August 19, 2023, and the shelf was heavily soiled. Further observation in the main kitchen on September 11, 2023, at 9:30 AM, revealed a bag of raisin bread without a date. Observation of the dry storage area on September 11, 2023, at 9:36 AM, revealed: one bag of granola labeled use by September 10, 2023; and two bags of potato chips labeled use by August 29, 2023. Observation of the ice machine in the main kitchen on September 11, 2023, at 9:43 AM, revealed the lid was dirty. When the surveyor looked inside the ice machine, the top of the inside of the ice machine was dirty with a black substance. Observation of one reach-in refrigerator unit in the main kitchen on September 11, 2023, at 9:45 AM, revealed a pan containing four saucers of diced peaches not labeled, dated, or covered. Observation of a reach-in freezer unit in the main kitchen on September 11, 2023, at 9:48 AM, revealed: one container of coffee cake with a use by date of July 1, 2023; one bag of meatloaf with a use by date of August 15, 2023; and one bag of meatballs with a use by date of August 15, 2023. Observation of a second reach-in refrigerator unit in the main kitchen on September 11, 2023, at 9:52 AM, revealed: two containers of beef base open without an open or a use by date; one container of pork base open without an open or use by date; one container of heavy whipping cream open without a date; and one container of horseradish labeled use by August 26, 2023. Observation of the walk-in refrigerator on September 11, 2023, at 9:56 AM, revealed: one bag of lettuce without a label or date; one bag of cilantro labeled use by September 6, 2023; and one bag of shredded parmesan cheese labeled use-by 8-18. Observation in walk-in freezer unit on September 11, 2023, at 10:03 AM, revealed: one bag of blue cheese crumbles with a use by date of March 8, 2023; one container of green beans open without a use by date; and one bag of raisin bread without a date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 12 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further observation of the walk-in freezer unit on September 11, 2023, at 10:05 AM, revealed food storage was stacked above the sprinkler head in the freezer. Observation during initial tour of the [NAME] pantry area refrigerator on September 11, 2023, at 10:12 AM, revealed: one container of chocolate syrup with a use by date of August 25, 2023, and one open can of Pepsi not dated or covered. Observation of the [NAME] pantry area dry storage on September 11, 2023, at 10:16 AM, revealed: one open container of pancake mix without a use by date; one bag of sugar packets without a date; one container of mustard open without a date; and one individual container of brown sugar not labeled or dated. Further observation of the [NAME] pantry area on September 11, 2023, at 10:16 AM, revealed the microwave was dirty with a brown substance on the inside, and there were no paper towels in the holder for the hand sink. Interview with Employee 7 (Dietary Supervisor) on September 11, 2023, at 10:20 AM, revealed she would expect the microwave to be cleaned after each meal service, paper towels to be stocked for handwashing, the ice machine and shelves in the kitchen to be clean, food not to be stocked above 18 inches from the ceiling, and food items to be labeled and dated per facility policy and discarded once past the use by date. Observation during initial tour of the Arlington pantry area on September 11, 2023, at 10:29 AM, revealed: one package of lemonade mix not dated; one bag of toasted o's cereal labeled use by August 22, 2023; two bags of potato chips labeled use by August 29, 2023; one container of oatmeal pies without an open or use by date; one container of fig bars without an open or use by date; and one container of powdered sugar on the counter not labeled or dated. Observation of the Arlington pantry area refrigerator on September 11, 2023, at 10:34 AM, revealed one tomato in a bin not dated. Observation of the Arlington pantry area freezer on September 11, 2023, at 10:36 AM, revealed: two bags of English muffins not dated, and one container of sherbet not dated. Interview with the Nursing Home Administrator on September 13, 2023, at 10:07 AM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored, cleaned, and utilized in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 13 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to consistently implement and maintain infection control practices, including PPE (Personal Protective Equipment) use, to prevent spread of the tuberculosis infection for one of 15 residents reviewed (Resident 41). Residents Affected - Some Findings Include: Review of Facility Policy, titled Tuberculosis Screening, last reviewed August 23, 2023, revealed, This center shall screen all residents for active tuberculosis (TB) .Nursing team members will place an appropriate mask over the mouth and nose of any resident having, or suspected of having active TB (whether based on X-ray results, clinical findings, or both), and will arrange for prompt transfer to an acute care hospital. Review of Resident 41's clinical record revealed documentation to indicate the Resident received a step-1 TB PPD test upon admission to the facility on July 13, 2023. Review of Resident 41's clinical record revealed an alert note on July 15, 2023, at 2:55 PM, that stated, Resident noted to have a large red area with a 5mm (millimeter- unit of measure) induration to left forearm at the site of her PPD test. On call physician notified and ordered chest x-ray, RP (responsible party) notified. Resident denies any past positive ppd tests or knowledge of TB exposure. She is asymptomatic at this time. Review of Resident 41's clinical record revealed a nursing note on July 15, 2023, at 9:27 PM, that stated, Call to [Employee 8 (Medical Doctor)], regarding chest x-ray result of chronic tuberculosis calcification, she is in agreement that future PPD's will have positive result, verbal order taken to discontinue 2nd step. DON (Director of Nursing) updated. Review of Resident 41's clinical record revealed a lab note on July 16, 2023, at 2:20 PM, that stated, X-Ray results reviewed with [Employee 8], New order to collect Quantiferon lab (TB blood test). RP updated. Review of Resident 41's clinical record revealed a nursing note on July 16, 2023, at 11:48 PM, that stated, Blood draw from left antecubital (A/C- arm), well tolerated. Blood taken to [Hospital] lab for TB Quantiferon. Review of Resident 41's clinical record revealed a nursing note on July 17, 2023, at 10:30 AM, that stated, Quantiferon Gold redrawn related to lab call for need of more blood. Blood drawn from the left A/C space on first attempt. Resident tolerated the procedure without difficulty. Gauze and band-aid applied after blood stopped. Blood sent to the lab on ice to be resulted. Review of Resident 41's clinical record revealed a change of condition note on July 20, 2023, at 7:07 AM, that stated, Resident's Quantiferon Gold results- Positive. DON called Medical Director and reported results. The trajectory (time frame) of the pathway from 7/13 admission PPD to Chest X-ray [48 hrs after PPD read] to positive Quantiferon Gold discussed. Medical Director notified ER (Emergency Room) physician and discussed resident's condition and testing results. DON notified the DOH (Department of Health) and received the information of required testing to confirm if TB is Active or Latent Phase. Resident with no cough present. Resident asymptomatic. Resident requiring a hospital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 14 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some transfer for further testing . Medical Director instructed DON to send resident to ED (Emergency Department) .DON instructed to send resident to ED and to instruct EMS to wear gown, gloves, N95 mask, and face shield. DON instructed to implement airborne precautions with staff. Resident wearing PPE when transferred out of facility. DON sent Chest X-ray and Quantiferon TB results to the DOH. Further Review of Resident 41's clinical record revealed no indication the Resident was placed on any precautions or PPE was placed in use, per facility policy, prior to July 20, 2023, at 7:07 AM. Interview with Employee 1 (Clinical Excellence Nurse) on September 14, 2023, at 12:09 PM, revealed she could not find any documentation to indicate Resident 41 had any transmission-based precautions in place for TB prior to July 20, 2023. During an interview with the Nursing Home Administrator on September 14, 2023, at 12:10 PM, the surveyor revealed the concern with no indication Resident 41 had any transmission-based precautions or PPE in place for TB prior to July 20, 2023. No further information was provided. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 15 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on employee education documentation review, facility documentation review, and staff interview, it was determined that the facility failed to ensure two of five nurse aides reviewed received at least 12 hours of education per year, which included dementia management and resident abuse prevention training (Employees 10 and 11). Findings include: Review of the facility's Job Description for the job titled Nursing Assistant (Nurse Aide), last revised November 8, 2017, revealed, General Responsibilities, included, [The employee] [c]ompletes educational requirements as mandated by state and federal agencies to maintain competencies. Review of facility documentation submitted by the facility on September 11, 2023, revealed that the Employee Education and Development trainings included, but not limited to, courses, titled Preventing, recognizing, and Reporting Abuse and dementia training, titled Teepa Snow: Dementia 101. Review of Facility documentation revealed that Employee 10 was hired for a Nurse Aide position on November 13, 2019. Review of Employee 10's facility education transcript revealed that, during the calendar year of 2022, Employee 10 only received 8.00 hours of annual training. Review of Employee 10's facility education for the 12 month period between September 12, 2022, and September 12, 2023, revealed that, during the 12 month period, Employee 10 completed only 2.00 hours of the facility's education. Further review of Employee 10's facility education revealed that Employee 10 had not completed the facility's training in Preventing, Recognizing, and Reporting Abuse in the years 2021, 2022, and up until review on September 13, 2023. Facility Employee 10 also did not receive the facility's specific training on residents with dementia in the years 2021, 2022, and up until the review on September 13, 2023. During a staff interview on September 14, 2023, at approximately 12:00 PM, Nursing Home Administrator (NHA) and Corporate Clinical Excellence Nurse confirmed that Employee 10 did not receive 12 hours of annual education, and did not receive annual training on the facility's abuse prohibition policies and residents with dementia. Review of Facility documentation revealed that Employee 11 was hired for a Nurse Aide position on October 2, 2019. Review of Employee 11's facility education transcript revealed that, during the calendar year of 2022, Employee 11 only received 7.75 hours of annual training. Review of Employee 11's facility education for the 12 month period between September 12, 2022, and September 12, 2023, revealed that, during the 12 month period, Employee 11 completed only 9.00 hours of the facility's education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 16 of 17 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 396146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Luther Ridge 2781 Luther Drive Chambersburg, PA 17202 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of Employee 11's facility education revealed that it had been more than 12 months since Employee 11 completed the facility's training in Preventing, Recognizing, and Reporting Abuse. Review of Employee 11's education transcript revealed the education was last completed on July 2, 2022. During a staff interview on September 14, 2023, at approximately 12:00 PM, the NHA and Corporate Clinical Excellence Nurse confirmed that Employee 11 did not receive 12 hours of annual education and did not receive annual training on the facility's abuse prohibition policies at least once every 12 months. 28 Pa code 201.14(a) Responsibility of the licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396146 If continuation sheet Page 17 of 17

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Citations

9 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0607GeneralS&S Dpotential for harm
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
0641GeneralS&S Epotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0692GeneralS&S Epotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0803GeneralS&S Dpotential for harm
F803 - Menus and nutritional adequacy
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.
0804GeneralS&S Dpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0947GeneralS&S Epotential for harm
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

FAQ · About this visit

Common questions about this visit

What happened during the September 14, 2023 survey of SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE?

This was a inspection survey of SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE on September 14, 2023. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SPIRITRUST LUTHERAN THE VILLAGE AT LUTHER RIDGE on September 14, 2023?

Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·September 14, 2023