Inspection·June 11, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in actual harm as evidenced by a fall with facial injury, which required sutures for one of three residents reviewed for falls (Resident 1). Findings include: Review of facility policy, titled Risk Management Incident/Accident Reporting Standard, with a last review date of May 21, 2025, revealed the facility identifies potential safety hazards, identifies residents at risk for accidents and/or falls and adequately plans care and implements procedures to prevent accidents. Review of facility policy, titled Resident Fall Prevention/ Prevention of Injury Standard, with a last revised date of November 28, 2017, and a last review date of May 21, 2025, revealed Residents will receive appropriate preventative measures and intervention to reduce risk for falls or injury; and Each member of the community, including team members, volunteers, and family members will support the safety of the residents' environment. Review of Resident 1's clinical record revealed diagnoses that included Parkinson's disease (a movement disorder that affects the nervous system and worsens over time), weakness, and dementia (loss of cognitive functioning that interferes with daily life and activities). Review of Resident 1's care plan revealed a focus area of, I am at risk for falls due to Parkinson's, history of falls, and generalized weakness, effective March 21, 2025. Review of interventions related to the focus area revealed the following intervention: I should be seated in a BRODA chair [specialty wheelchair] in tilt position with L[left] lateral support at all times except full upright for meals to facilitate increased comfort and pressure reduction. The specialty chair is not considered a restraint for me as it does not change my transfer status and ability to get up from a seated position, effective March 21, 2025. Review of facility incident report dated June 2, 2025, revealed that at 11:20 AM two therapy staff heard Resident 1 calling for help upon entering the nursing unit. Resident 1 was found in the common area on the floor in front of her broda chair, sitting on her bottom while bracing herself with her arms behind her back. Blood was noted on her hands, face, neck and clothing from a gash below her right eye. When asked, Resident 1 stated she was reaching for a block on the floor and fell out of her chair. No block was present on the floor. 911 was called and Resident 1 was transported to the (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 3 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 06/11/2025 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)