Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Artman Lutheran Home during CMS and state inspections, most recent first.
A facility failed to complete a thorough investigation after a resident with severe cognitive impairment and max-assist transfer needs fell in the bathroom and sustained an acute hip fracture. Statements were inconsistent about whether a paid companion and staff assisted with toileting and transfers, and the record showed conflicting accounts of whether the companion picked the resident up from the floor and helped move him back to the toilet or wheelchair. The investigation included some witness statements, but the documentation did not fully reconcile the events surrounding the fall and transfer.
A resident with dementia, dysphagia, and multiple mobility and vision impairments was observed eating lunch in bed despite an NP note stating the resident had been fed lying in bed and had chronic coughing related to poor posture and swallowing difficulty. After the family reported a prolonged coughing episode, the NP recommended that all meals be taken out of bed in a chair to reduce aspiration risk, but the resident’s physician orders did not show that the recommendation was acknowledged.
A resident with dementia, impaired mobility, and dependence for toileting and transfers was placed on the toilet by two facility staff members and left with a companion outside the bathroom. The resident stood up, fell to the floor, and the companion picked the resident up and put him back on the toilet before staff were fully involved. The resident later reported hip pain, and an x-ray showed an acute left femoral intertrochanteric fracture.
A resident's individualized care plan required the use of a functioning chair alarm to alert staff of unassisted rising. However, the chair alarm was not connected properly, resulting in the resident being found on the floor after a fall. The DON confirmed the alarm was not in place as specified in the care plan, and the deficiency was identified through review of records and staff interviews.
A resident received a pneumococcal vaccine without documented screening for contraindications or precautions, as required by facility policy and CDC guidelines. The infection preventionist confirmed that screening was not completed prior to vaccine administration.
Surveyors found that multiple residents were unaware of their right to file grievances anonymously, and there was no clearly designated area or box for submitting anonymous grievances, despite facility policy and posted notices indicating this right. The only available box was labeled as a suggestion box, and residents did not recognize it as a means to file anonymous grievances.
A resident with cardiac conditions sustained burn injuries after spilling coffee on herself in bed. The incident was not immediately reported to the State Survey Agency as required by facility policy and state regulations, constituting a failure to report suspected neglect.
A resident with cardiac conditions suffered burns after spilling coffee, and the facility did not obtain required written witness statements from involved staff, resulting in an incomplete investigation into the alleged neglect.
The facility administered COVID-19 vaccines to multiple residents without completing the required pre-vaccination screenings for contraindications or precautions, as mandated by CDC guidelines and facility policy. This was confirmed by documentation review and staff interview.
A resident with heart failure and atrial fibrillation was found on the floor with a head hematoma after a broken bed rail failed to lock in place. The facility did not have a scheduled maintenance program for bed rails, checking them only when preparing rooms for new admissions, contrary to its policy requiring regular assessments.
The facility failed to provide education on the benefits and side effects of influenza immunization to two residents, as required by their policy. The Director of Nursing confirmed that consent forms are given only upon admission, and there was no documented evidence of education being provided before offering the vaccine.
A facility failed to create a comprehensive care plan for a resident with impaired skin integrity. The resident, who had memory issues and was at risk for pressure ulcers, developed a deep tissue injury on the right fifth toe. Despite facility policy requiring a care plan within seven days of the MDS assessment, no plan was documented to address the resident's skin condition.
A dietary aide in an LTC facility failed to follow the policy for reheating food, serving a resident with cognitive impairment and dementia a hot dog and beans without checking the temperature or allowing it to cool. The facility's policy required food to be stirred or rotated and allowed to stand covered for two minutes to ensure it was under 180°F, but this procedure was not followed.
A resident with a physician order for nectar consistency liquids was provided with regular consistency orange juice, contrary to their dietary needs. This was confirmed by a nurse aide during an observation.
The facility failed to designate a qualified infection preventionist to oversee the infection prevention and control program. The Director of Nursing, who was also the infection preventionist, lacked documented evidence of part-time work in this role, leading to non-compliance with the program's requirements.
The facility failed to provide appropriate ADL assistance for two residents. A resident with moderate cognitive impairment did not receive scheduled showers on multiple occasions, as confirmed by the DON. Another resident, who prefers bed baths due to a colostomy bag, was observed with poor personal hygiene and expressed a desire for grooming assistance, which was not provided. This failure violated resident rights and nursing services regulations.
A facility failed to follow physician orders for a resident, including a toileting schedule and the use of tubi-grips, leading to care deficiencies. Documentation showed missed toileting attempts, and observations confirmed the absence of tubi-grips. Additionally, broken wheelchair footrest loops were noted for two residents, with initial reports suggesting they were unnecessary, indicating lapses in care and equipment maintenance.
Incomplete investigation of resident fall with hip fracture
Penalty
Summary
The facility failed to ensure a complete and thorough investigation for a resident who sustained an acute left femoral intertrochanteric fracture after an incident in the bathroom. The resident had severe cognitive impairment, was non-ambulatory, and required maximum assistance of 2 people for transfers. According to the reportable incident, the resident was assisted onto the toilet by a nurse aide and a nursing supervisor and was left there with a paid companion, who was instructed to ring the call bell when the resident was ready to get up. The incident documentation and witness statements were inconsistent regarding what happened after the resident was left on the toilet. The companion stated that the resident stood quickly, fell to the floor, and that she picked him up and put him back on the toilet. The nurse aide and licensed nurse reported that the companion told them the resident fell off the toilet and was picked up from the floor and returned to the toilet. The nursing supervisor stated that companions are not allowed to assist with resident transfers, and that residents require two staff members for transfers. During interviews, the nurse aide later stated that both she and the companion transferred the resident from the toilet to his wheelchair, while the companion stated she was not allowed to provide care or transfer residents and also reported that she assisted the nurse aide with the transfer to the wheelchair. The facility’s investigation included statements from the licensed nurse, nursing supervisor, and companion, but the report states that the nurse aide’s interview did not reveal a statement that she had the companion assist with transferring the resident from the toilet back to the wheelchair. The record also contained differing accounts of whether the companion was outside the bathroom doorway, in the doorway, or in the room, and whether she assisted after the fall. The resident complained of hip pain, x-rays showed an acute left hip fracture, and he was sent to the hospital emergency room for treatment.
Failure to Acknowledge Meal Positioning Recommendation
Penalty
Summary
The facility failed to acknowledge a nurse practitioner’s recommendation regarding a resident’s positioning during meals for one resident with dementia, arthritis, macular degeneration, difficulty walking, a left hand contracture, a prior left femur neck fracture, and dysphagia. The resident’s MDS indicated cognitive impairment. During an observation, the resident was seen eating lunch in bed in the room with a companion present. A nurse practitioner note documented that the resident had been fed lying in bed and had an occasional moist, non-productive cough that was described as chronic due to poor posture and difficulty swallowing. After being contacted by the facility because of concerns from the resident’s daughter about a coughing fit lasting over an hour, the nurse practitioner assessed the resident and recommended that all meals be taken out of bed in a chair to reduce the risk of aspiration. Review of the resident’s April and May physician orders did not show evidence that this recommendation was acknowledged by the facility.
Failure to Supervise Toileting and Use Staff for Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received supervision during toileting and was transferred by facility staff after a fall in the bathroom. Resident R37 had dementia, arthritis, macular degeneration, dysphagia, difficulty walking, a contracture of the left hand, and a fracture of the unspecified part of the neck of the left femur. The resident’s MDS indicated cognitive impairment, and the resident was dependent on staff for toilet hygiene, sit-to-stand transfer, lower body dressing, and toilet transfers. Companion agency documentation stated that facility staff were responsible for all personal care and transfers, and that companion staff were to alert facility staff when personal care was needed. During the toileting incident, two facility staff members transferred the resident to the toilet and instructed the companion to ring the call bell when the resident was finished. The companion was positioned outside the bathroom doorway. Staff statements and interviews described that the resident stood up quickly from the toilet and fell to the bathroom floor. The companion reported that she could not get to the resident in time to prevent the fall. The companion then picked the resident up from the floor and placed him back on the toilet. Other statements indicated that the companion also assisted with moving the resident after the fall. After the incident, the resident complained of hip pain. An x-ray obtained at the facility showed an acute left femoral intertrochanteric fracture, and the resident was sent to the hospital emergency room for treatment. Interviews with nursing staff and the companion confirmed that the resident required two staff members for transfers and that companions were not permitted to assist with transfers, yet the resident was left with the companion during toileting and was transferred from the floor by the companion after the fall.
Failure to Implement Care Plan Intervention for Chair Alarm
Penalty
Summary
The facility failed to implement a care plan intervention for a resident by not ensuring the proper use of a chair alarm as specified in the individualized care plan. The care plan, dated September 5, 2025, required the use of an electronic chair alarm to alert staff of unassisted rising, with instructions to ensure the device was in place every shift. On October 7, 2025, the resident was found on the floor in their room, with the fall investigation revealing that the chair alarm was not connected properly at the time of the incident. The resident's fall prevention measures included bed and chair alarms, hourly checks due to poor safety awareness and fall risk, nonskid socks while in bed, and staff supervision in the bathroom. The Director of Nursing confirmed that the chair alarm was not connected as required by the care plan when the fall occurred. The deficiency was identified through a review of clinical records, the facility's fall investigation, and staff interviews, which established that the intervention to provide a properly functioning chair alarm was not implemented as directed in the resident's care plan.
Failure to Screen Resident Prior to Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that pneumococcal immunization was provided according to professional standards of practice for one resident. Facility policy states that all residents will be offered the pneumococcal vaccine per CDC recommendations and that effective screening for contraindications and precautions must be completed prior to vaccine administration. Documentation review showed that a resident received the pneumococcal vaccine, but there was no evidence in the clinical record of completed screening prior to immunization. An interview with the infection preventionist confirmed that the facility does not complete screening for pneumococcal immunizations before administration.
Failure to Ensure Residents' Right to File Anonymous Grievances
Penalty
Summary
Surveyors determined that the facility failed to ensure residents were aware of and able to file grievances anonymously, as required by facility policy and resident rights regulations. During interviews with nine alert and oriented residents, all stated they were not aware of their right to file grievances anonymously. Observations revealed that, although a sign indicated residents could file grievances anonymously, there was no clearly designated area for submitting anonymous grievances, and the only available box was labeled as a suggestion box. The facility's policy referenced locked boxes for anonymous grievances, but these were not observed to be in place or clearly identified for this purpose at the time of the survey.
Failure to Report Suspected Neglect Following Resident Burn Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for one resident. According to facility policy, any suspected or alleged abuse must be reported to the Department of Health, and investigations should include witness interviews and signed statements. However, for one resident with a history of heart failure and atrial fibrillation, this protocol was not followed after an incident involving a burn injury. The incident involved a resident who spilled coffee on herself while in bed, resulting in scattered intact blisters on her right abdominal area, under her right breast, and upper right thigh. The resident did not immediately report the injury to nursing staff, and when the incident was discovered, the Director of Nursing confirmed that it was not reported to the State Survey Agency as required by policy and regulation. This omission constituted a failure to report suspected neglect in accordance with state requirements.
Failure to Complete Investigation into Alleged Neglect
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of possible neglect involving a resident with heart failure and atrial fibrillation. The resident reported spilling coffee on herself, and upon assessment, was found to have scattered intact blisters on her right abdominal area, under her right breast, and upper right thigh. Although the facility's policy requires obtaining written witness statements as part of the investigation process, the facility did not secure these statements from the dining coordinator who placed the coffee on the tray or the aide who served the coffee. This omission resulted in an incomplete investigation into the incident, as required by facility policy and state regulations.
Failure to Complete Required Screening Prior to COVID-19 Vaccination
Penalty
Summary
The facility failed to provide COVID-19 immunizations according to professional standards of practice for 35 out of 73 residents reviewed. Facility policy required that all residents, staff, and volunteers be offered the COVID-19 vaccine per CDC recommendations, and that vaccines be administered by qualified personnel under standing orders. CDC guidelines specify that effective screening for contraindications and precautions must be completed before administering any vaccine dose. Documentation review showed that multiple residents received COVID-19 immunizations on various dates. However, there was no evidence in the clinical records that screenings were completed prior to the administration of the vaccines for these residents. The absence of completed screenings meant that the facility did not determine whether residents had any medical contraindications or precautions before immunization, as required by both facility policy and federal regulations. An interview with the facility's infection preventionist confirmed that screenings were not completed for the listed residents prior to their COVID-19 immunizations. This failure to follow established procedures and professional standards resulted in a deficiency under the cited regulation.
Failure to Regularly Inspect and Maintain Bed Rails
Penalty
Summary
The facility failed to implement a scheduled maintenance program for bed rails as required by its own policy, which states that individual bed rail assessments and evaluations should be performed regularly. A resident with a history of heart failure and atrial fibrillation was admitted and later experienced an incident where they were found on the floor with a hematoma to the left side of the head. Nursing documentation revealed that the right-side bed rail was broken and would not lock in place at the time of the incident. The Director of Maintenance confirmed that prior to the incident, bed rails were only checked when preparing a room for a new admission, and not on a regular schedule.
Failure to Educate Residents on Influenza Immunization
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of influenza immunization to two residents, R29 and R14, as required by their policy. The facility's policy mandates that each resident should be protected against the influenza virus, with the vaccine offered annually. The policy also requires that if a resident or their representative declines the vaccine, education about the risks and complications of not receiving it should be discussed. However, upon review of the clinical records for Residents R29 and R14, there was no documented evidence that they received the necessary education before being offered the influenza immunization. An interview with the Director of Nursing, Employee E2, revealed that consent forms for vaccinations are provided only upon admission, and residents are verbally asked if they want the vaccines at the beginning of each flu season. Employee E2 confirmed that there was no documented evidence of education being provided to the residents or their representatives regarding the benefits and potential side effects of the influenza immunization. This lack of documentation and education constitutes a deficiency in the facility's adherence to its vaccination policy.
Failure to Develop Comprehensive Care Plan for Skin Integrity
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for a resident identified as R26, who had impaired skin integrity. The facility's policy requires that a care plan be developed for each resident, including measurable objectives and timetables to meet their medical, nursing, mental, and psychosocial needs. This care plan should be developed within seven days of the submission of the complete Minimum Data Set (MDS) assessment. However, upon review of Resident R26's quarterly MDS, it was noted that the resident had short and long-term memory problems and was at risk of developing pressure ulcers. Despite this, the facility did not document a care plan addressing the resident's impaired skin integrity, even after a skilled wound report indicated the presence of a deep tissue injury on the resident's right fifth toe, with an onset date of July 11, 2024.
Failure to Ensure Safe Food Temperatures
Penalty
Summary
The facility failed to implement procedures to ensure food was served at safe, appetizing temperatures for a resident observed in the dining room. The facility's policy on food temperatures, which was undated, stated that microwave reheating is appropriate when a resident requests it, and the food should be stirred or rotated and allowed to stand covered for two minutes to ensure the temperature is under 180 degrees Fahrenheit. However, during an observation, a dietary aide heated a plate of food for a resident with moderate cognitive impairment and diagnoses of muscle weakness and dementia. The dietary aide handed the plate directly to a nurse aide without checking the temperature or allowing it to sit, as required by the policy. This was confirmed in an interview with the dietary aide, who acknowledged that the temperature was not checked to ensure it was safe.
Failure to Provide Nectar Consistency Liquids
Penalty
Summary
The facility failed to provide beverages consistent with the needs of a resident, identified as Resident R17, who required altered fluid consistency. A review of Resident R17's clinical record showed a physician order dated August 18, 2024, specifying that the resident was to receive nectar consistency liquids. However, during an observation on August 21, 2024, at 10:00 a.m., it was noted that Resident R17's breakfast tray included orange juice of a thin, regular consistency, contrary to the nectar thick liquids indicated on the meal ticket. This discrepancy was confirmed in an interview with Nurse Aide, Employee E3, who acknowledged that the wrong beverage was provided to Resident R17.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist to be responsible for the infection prevention and control program. The facility's Infection Control Program Overview outlines the goals and responsibilities for infection control, including the need for a designated infection control practitioner. However, the facility did not have a designated individual working at least part-time as an infection preventionist, as required by the program. The Director of Nursing, Employee E2, was identified as the infection preventionist, but there was no documented evidence of her working part-time in this role. Interviews with Employee E2 revealed that she was the full-time Director of Nursing and the only employee with an infection control certification. Despite her dual role, there was no documentation to support her part-time work as an infection preventionist. This lack of documentation and formal designation led to the deficiency, as the facility did not comply with the requirement to have a designated infection preventionist working at least part-time.
Failure to Provide Scheduled ADL Assistance
Penalty
Summary
The facility failed to provide appropriate assistance with Activities of Daily Living (ADL) for two residents who were unable to perform these tasks independently. Resident R1, who has a moderately impaired cognitive status with a BIMS score of 8, was dependent on staff for showers, transfers, and toileting. Despite being scheduled for showers on Wednesdays and Saturdays, Resident R1 did not receive showers on several Wednesdays in May and June 2024, as confirmed by the Director of Nursing. Resident R3, who prefers bed baths due to having a colostomy bag, was observed with unkempt personal hygiene, including mid-size facial hair, long greasy hair with white flakes, and long nails. Resident R3 expressed a desire to have their hair, facial hair, and nails trimmed but was unable to do so independently. This observation was confirmed by a Licensed Nurse, Employee E5. The facility's failure to provide scheduled showers and personal grooming assistance violated resident rights and nursing services regulations.
Failure to Follow Physician Orders and Maintain Equipment
Penalty
Summary
The facility failed to adhere to physician orders for a resident, leading to deficiencies in care. The orders included a specific toileting schedule, the use of tubi-grips on the resident's lower extremities, and the placement of a gel cushion on the resident's wheelchair. However, documentation revealed that the 11:00 a.m. toileting attempt was not recorded on numerous dates, and observations confirmed that the resident was not taken to the bathroom as scheduled. Additionally, during an observation, it was noted that the resident was not wearing tubi-grips as ordered, and the responsible nurse admitted to forgetting and discovered that none were available, indicating a lapse in following the prescribed care plan. Further observations highlighted issues with the resident's wheelchair, as the footrest heel loops were broken, which could affect the resident's safety and comfort. Another resident at the same dining table also had a broken footrest loop. The Rehabilitation Director replaced the broken parts but initially reported that the loops were unnecessary. These findings demonstrate a failure to implement and maintain physician-ordered care and equipment checks, compromising the quality of care provided to the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ambler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ambler Extended Care Center | 0.6 mi | ★★★★★ | 7 | 0 |
| Silver Stream Rehabilitation And Nursing Center | 1.3 mi | ★★★★★ | 13 | 0 |
| Willowbrooke Court-spring Hous | 1.3 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Ctskdcarectr At Fortwashingtonestates | 1.6 mi | ★★★★★ | 3 | 0 |
| Dresher Hill Health And Rehabilitation Center | 2.7 mi | ★★★★★ | 14 | 0 |
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