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 a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey, completed on April 30, 2026, it was determined that Artman Lutheran Home was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania of Long Term Care Licensure regulations related to the health portion of the survey process.

Plan of Correction:

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

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.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Plan of Correction - To be completed: 07/01/2026

It is the policy of Artman Lutheran Home to complete a thorough investigation of all incidents.
The Director of Nursing will ensure that all incidents are thoroughly and completely investigated per Artman's policy. All incident reports will be signed off by the interdisciplinary team ASAP. An incident log will be maintained by the DON monthly x 3 months and until 100% compliance is achieved. The NHA will review all incident reports for completed investigation and statements x 3 months and 100% compliance is achieved.
All audits will be kept on file for review. Both the NHA and DON reviewed the investigation policy on April 30,2026. All supervisory staff will be re-educated on how to conduct an investigation and statements needed by 6/20/2026--education will be completed by the DON and signed in-service records will be kept on file for review.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations: Based on observations and the review of clinical records it was determined that the facility failed to acknowledge a physician recommendation regarding a resident's positioning during meal times for 1 out of 14 residents reviewed (Resident R37). Findings include: Review of the April 2026 physician orders for Resident R37 included the following diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life); arthritis (the swelling and tenderness of one or more joints); macular degeneration (age related eye condition in which individuals cannot see things directly in front of them); difficulty walking; contracture of left hand, and fracture of unspecified part of neck of left femur and dysphagia (difficulty swallowing). Review of the resident's Comprehensive Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated December 18, 202,5 indicated that the resident was cognitively impaired. During an observation on April 29, 2026, at 12:30 p.m. the resident was observed eating lunch in (his/her) room in the bed with his companion present. Review of a note from nurse practitioner (Employee E11) dated April 14, 2026, at 1:00 p.m. stated that the resident was seen on the above referenced date with concerns from the resident's daughter that the resident had a "coughing fit" that last for over an hour. Continued review of the nursing note indicated that since the above referenced incident that the daughter described, the note documented that the resident continued to have "an occasional moist, non-productive cough," and that this is chronic for the resident due to the resident's poor posture and difficulty in swallowing. Continued review of the above referenced documentation from the nurse practitioner documented that the resident was being fed lying in his bed. The nurse practitioner recommended for the resident to have all of his meals out of bed in his chair to reduce the risk of aspiration (occurs when something that's supposed to be in an individual's stomach like food, water or gastric acid or anything that isn't air gets into your airways which can lead to complications like airway blockage and infections). Review of the resident's April 2026 and May 2026 physician orders did not show evidence that the nurse practitioner's recommendations were acknowledged by the facility. During an interview with the nurse practitioner on April 30, 2026, at 1:00 p.m. the nurse practitioner reported that the family and the facility were both concerned about coughing and she was contacted by the facility to assess the resident. She reported that she made the above referred recommendation after her assessment to have the resident eat out of bed to the nursing staff. 28 Pa. Code 211.10(c)(d) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 07/01/2026

It is the policy of Artman Lutheran Home to follow all recommendations and orders from the Physician and Physician Extenders. Education was provided to the NP on April 30, 2026 to ensure that all recommendations are put in as orders and to inform the nursing staff that new orders are in. The Medical Director was also informed on April 30, 2026. Random checks of MD and NP notes will be reviewed 10/month x 3 months by the DON or NHA to ensure that all recommendations will be ordered. Audits will kept on file for review. audits will be completed by 8/31/2026

The resident was assessed again on April 30, 2026 by the NP and discussed that the recommendation no longer applied and would not be written as an order. NP to document in medical record. Resident was also assessed by speech therapy and no new recommendations noted.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations: Based on staff interviews and the review of clinical documentation, it was determined the facility failed to ensure that a resident received supervision during toileting and was transferred by facility staff members after sustaining a fall incident in the bathroom for one of 14 residents reviewed. (Resident R37) Findings include: Review of "Companion Services/Private Caregivers" policy with a revision date of July 26, 2018, revealed it is the policy of the facility to obtain documentation of services to be provided by a companion or private caregiver from the resident representative or employer. Review of Resident R37's clinical record revealed April 2026 physician orders including the following diagnoses: Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life); Arthritis (swelling and tenderness of one or more joints); Macular Degeneration (age related eye condition in which individuals cannot see things directly in front of them); Dysphagia (difficulty swallowing); difficulty walking; contracture of left hand, and fracture of unspecified part of neck of left femur. Review of Resident R37's clinical record revealedResident R37's Comprehensive Minimum Data Set Assessment (MDS- periodic assessment of a resident's needs) dated December 2, 2025, indicated the resident was cognitively impaired. Continued review of the MDS assessment revealed the resident was dependent on staff for toilet hygiene, sit to stand transfer, lower body dressing and toilet transfers. Review of Resident R37's "Care Needs" as noted by the companion agency who employed Resident R37's companion dated November 11, 2025, to current revealed, facility staff are to do all personal care for the resident. Additional review of same document revealed for Resident R37's personal care and toileting, the resident's "Care Needs" indicated "Artman staff is responsible for all transfers and personal care. Continue review of the companion agency documentation revealed the companion agency staff were to alert facility staff when personal care is needed by the resident. Review of Resident R37's Activities of Daily Living (ADL's) as noted by the companion agency dated November 11, 2025, to current; revealed companion staff should request transfers from facility staff for the resident on all shifts. Review of information submitted March 14, 2026, by the facility to the Department, revealed Resident R37's nurse aide found the resident sitting on the toilet in the bathroom located in (his/her) room, accompanied by (his/her) companion from the 7:00 a.m. to 3:00 p.m. nursing shift. Continued review of information revealed the resident's companion indicated the resident fell off the toilet and (the companion, Employee E8) picked the resident up and put him back on the toilet. Further review of the documentation revealed Resident R37 had severe cognitive impairment, non- ambulatory and needed the maximum assistance of two people for transfers. Continued review of the information revealed the companion reported the resident was standing outside of the bathroom when she saw the resident stand quickly and fall to the floor. Additional review of the information revealed the companion indicated she could not get to the resident in time to prevent the fall. Further review of the information revealed the resident complained of hip pain. An x-ray was obtained at the facility, and the results of the x-ray showed the resident sustained an acute left femoral intertrochanteric fracture (left hip fracture). Continued review revealed the resident was sent to the hospital emergency room for treatment. Review of Employee E4's (nurse aide) witness statement dated March 14, 2026, regarding the above-referenced incident revealed the nurse aide reported both she and the licensed nurse (Employee E10) put the resident on the toilet and informed the companion to ring the call bell when the resident was finished.Nurse aide reported that the companion told her the resident fell and then she informed the nurse. During interview with the nurse aide, Employee E4 on April 30, 2026, at 1:08 p.m. the nurse aide revealed both she and the licensed nurse supervisor (Employee E10) put the resident on the toilet and the resident fell off the toilet when the resident was left with the companion. Nurse aide, Employee E4 revealed the companion was standing in the bathroom doorway after Licensed nurse, Employee E10 put the resident on the toilet. Nurse aide, Employee E4 revealed the companion told her that she took the resident off the floor and put the resident back on the toilet. Nurse aide, Employee E4 revealed she informed another nurse (Employee E9) what the companion had confided to her about the resident falling off the toilet and the companion picking the resident up from the floor and put the resident back onto the toilet. During interview with Licensed nurse (Employee E9) on April 30, 2026, at 1:34 p.m. revealed that nurse aide (Employee E4) notified her that the resident fell off the toilet and the resident's companion picked him off the floor and put him back on the toilet so the resident could finish using the bathroom. Licensed nurse, Employee E9 reported she notified the nurse supervisor (Employee E10). Licensed nurse, Employee E9 revealed when she walked into the resident's room after the nurse aide called, the resident was observed sitting in his wheelchair next to the table in his room facing the door. Review of the facility's investigation did include a written statement from licensed nurse (Employee E9). During follow up interview with nurse aide (Employee E4) on April 30, 2026, at 1:45 p.m. the nurse aide revealed the resident was on the toilet when she went back into the bathroom to answer the call bell, and that both she and the companion transferred the resident from the toilet to the resident's wheelchair. Review of written statement by nursing supervisor (Employee E10) dated March 14, 2026, revealed nursing supervisor indicated she assisted the nurse aide (Employee E4) with transferring the resident to the toilet. The nursing supervisor reported in her statement she instructed the resident's companion to ring the call bell when the resident was finished using the bathroom. Interview conducted with nursing supervisor (Employee 10) on April 10, 2026, at 1:47 p.m.nursing supervisor reported she helped the nurse aide transfer the resident to the bathroom toilet located in the resident's room. Nursing aide indicated the companion was sitting on the chair across from the resident outside of the bathroom in the resident's room when they left the room. Nursing supervisor reported she instructed the companion to pull the call bell in the resident's room when the resident was finished using the bathroom. Nursing supervisor revealed the licensed nurse (Employee E9) came to her and informed her that the resident fell off the toilet and the companion picked the resident up. Nurse supervisor indicated she went to the resident's room, and the resident was sitting in his wheelchair. Nurse supervisor reported, she spoke with the companion and was informed by the companion the resident stood up from the toilet and by the time she got to the resident, the resident fell to the bathroom floor. Nurse supervisor reported she was "pretty sure" the nurse aide (Employee E4) and the companion transferred the resident from the toilet to the chair. Nursing supervisor reported Resident R37 requires two staff members for transfers and companions are not permitted to assist staff with transferring a resident in the facility. Review of written statement by Resident R37's companion (Employee E8) revealed the companion reported the resident was on the toilet and she was waiting outside the bathroom when she saw the resident quickly stand. The companion reported in her statement she tried to go towards the resident but the resident fell before she could get to the resident. Continued review of the companion's statement revealed she picked the resident from the floor and sat the resident back on the toilet. Interview conducted with companion (Employee E8) on May 11, 2026, at 1:20 p.m. revealed she works as a paid companion from a nursing agency for shift times of 7:00 a.m. through 7:00 p.m. every other Saturday. Employee E8 reported that she is not permitted to provide personal care or transfer residents. Continued interview with the companion regarding the incident of March 14, 2025, revealed the resident was transferred to the toilet by two staff members of the facility and she stood outside the bathroom door with the door open, to provide the resident privacy. The companion revealed, the resident stood up quickly that she could not do anything about it. Resident R37's companion, Employee E8 reported that she ran to the resident as soon as she saw him stand. The companion revealed Resident R37 fell; then she picked the resident up from the bathroom floor and pulled the call bell in the bathroom for help. Companion reported that she did assist the nurse aide (Employee E4) with transferring the resident to his wheelchair once the nurse aide came in. During an interview with the Director of Rehabilitation on April 30, 2026. at 2:41 p.m. it was confirmed that the resident's transfer status at the time of his fall required the resident to have the assistance of two staff members. During an interview with the Director of Nursing (DON) on April 30, 2026, at 2:25 p.m., concerns for Resident R37's supervision and safety were discussed. Further it was discussed with the facility Director of Nursing that the resident was transferred off the floor after a fall incident in the bathroom and into a wheelchair by a companion. 28 Pa. Code 211.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 07/01/2026

It is Artman Lutheran Home's policy to ensure that residents receive proper supervision and transfers are completed by facility personnel only. Residents are also assessed by a licensed staff member after an incident.
Education will be provided to nursing staff on supervision and post incident procedures by the DON/designee by 7/1/2026. In-service records will be maintained on file and available for review. All incident and investigations will be reviewed x 3 months and until 100% compliance is achieved. Audits will completed by the DON/designee and reviewed by the NHA. Audits will be completed by 8/31/2026 and records will be maintained for review.

Private caregivers-- agency and family were notified that Artman staff provides all care to resident upon admission. Agency and private companion was again in-serviced on March 14, 2026 and April 30, 2026. Private duty care plan was updated and agency provided review/education of care plan to all their caregivers. Ongoing monitoring will be done by Artman staff to ensure compliance.

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