Pennsylvania Department of Health
ARTMAN LUTHERAN HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ARTMAN LUTHERAN HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on December 11, 2025, it was determined that Artman Lutheran Home was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations: Based on the review of clinical records, facility fall investigation, it was determined that the facility failed to implement a care plan intervention for Resident R1 by not providing a properly functioning chair alarm as specified in the resident's individualized care plan for one of five residents reviewed. (Resident R1). Findings Include: Review of Resident R1's care plan dated September 5, 2025, revealed an intervention requiring the use of an electronic chair alarm to alert staff of unassisted rising. Ensure the device is in place every shift. Review of Resident R1's fall investigation dated October 7, 2025, revealed that the resident was found lying on his right side in his room on the floor with his head against the wall and his legs still positioned on his leg rests. Further review of the investigation revealed that current fall preventions included: bed and chair alarm to alert staff of unassisted rising, hourly checks due to poor safety awareness and fall risk, nonskid socks while in bed, and staff to remain with resident at all times while in the bathroom. Continued review of the investigation revealed that Resident R1's chair alarm was not connected properly when fall occurred. Interview with the Director of Nursing, Employee E2, on October 14, 2025, at 12:00 p.m. confirmed that Resident R1's chair alarm was not connected properly as per the care plan when he fell on October 7, 2025. This deficiency was cited as past non-compliance. Review of facility Action plan/Follow up documentation revealed the following information. 1. Resident R1's call bell was connected properly and interventions added to ensure functioning every shift. 2. All residents with bed or chair alarms were checked immediately to ensure they were on and functioning. 3. The Director of Nursing educated the nursing assistant responsible on 10/8/2025. The Unit Manager in-serviced the clinical team on all shifts; completed on 10/12/2025. 4. Audits will be completed weekly on the household by the Unit Manager on residents that have alarms x 3 months and 100% compliance is achieved. Use of Bed and Chair alarms are very minimal in community. Plan of Correction will be reviewed by team in QAPI monthly meetings until completed. Facility date of compliance was October 12, 2025. A review was conducted of clinical records, facility documentation, staff education, and documentation of audits conducted by the facility. Interview with staff revealed that the staff was knowledgeable about the facility bed/chair alarm policy. It was determined that the plan of correction was implemented and identified as past non-compliance. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 12/11/2025

Past noncompliance: no plan of correction required.

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