Health inspection·October 20, 2023

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 interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of two residents reviewed (Residents R134 and R136). Residents Affected - Few Findings include: Review of Resident R134's Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 9/25/23, indicated the resident was admitted to the facility on [DATE]. It was indicated the resident was discharged on 9/25/23, to the hospital. Review of Resident R134's progress note dated 9/25/23, indicated the resident was discharged to a personal care home. Review of Resident R136's MDS dated [DATE], indicated the resident was admitted to the facility on [DATE]. It was indicated the resident was discharged on 8/7/23, to the community. Review of Resident R136's progress note dated 8/7/23, indicated the resident sent to the emergency room. It was stated it was unclear if he will be discharged home from there our back to the facility. Review of Resident R136's progress note dated 8/7/23, indicated the resident was admitted to the hospital. During an interview on 10/18/23 at 12:53 p.m., Registered Nurse Assessment Coordinator (RNAC), Employee E1 confirmed the facility failed to ensure complete and accurate MDS assessments were completed for two of three residents reviewed (Residents R134 and R136). 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(5) Nursing services Page 1 of 10 395684 395684 10/20/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to for a resident's tube feed in order to maintain a resident's highest practicable physical well-being as required for one of six residents reviewed. (Resident R114) Findings include: Review of Resident R114's Minimum Data Set (MDS-periodic assessment of care needs) dated 9/26/23 indicated Resident R144 was admitted to the facility on [DATE] with diagnosis of malnutrition, dysphagia (difficulty swallowing), and high blood pressure. Review of Resident R114's physician order dated 9/15/23, indicated to check tube placement prior to medication, feedings, and flushes and document the amount of formula and water provided every eight hours. Review of Resident R114's physician order dated 10/5/23, indicated to administer Osmolite 1.2 (a type of tube feeding supplement) via jejunostomy tube (J-tube is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) at a rate of 45cc/hour for 20 hours from 6 p.m. until 2 p.m. Review of Resident R114's clinical record on 10/18/23, failed to reveal a resident-centered plan of care with goals and interventions related to her tube feed. During an interview on 10/18/23 at 10:30 a.m., Registered Nurse Assessment Coordinator (RNAC), Employee E1 confirmed the facility failed to develop a care plan to include a focus and interventions for Resident R114's tube feed. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: §211.10(c) Resident care policies 395684 Page 2 of 10 395684 10/20/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to follow a order as prescribed by the physician for one of four residents (Resident R66). Residents Affected - Few Findings include: A review of the facility policy, Consulting Physician/Practitioner Orders dated 10/17/22, last reviewed 1/6/23, indicated for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will call the attending physician to verify the order, document the verification order by entering the order and the time, date, and signature in the electronic health record, and follow facility procedures for verbal or telephone orders including, nothing the order, submitting to pharmacy, and transcribing medication or treatment admiration record. A review of the clinical record indicated Resident R66 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infraction, muscle weakness and dysphagia. A review of Resident R66's quarterly MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 9/29/23, indicated the diagnosis remained current. A review of clinical physician orders last order review 10/17/23, indicated to record intake and output every shift. A review of Resident R66 indicated no output was recorded 9/5/23-9/10/23. During an interview on 10/20/23, at 10:23 a.m. the Director of Nursing confirmed the above findings and the facility failed to follow physician's orders for Resident's R66. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services. 395684 Page 3 of 10 395684 10/20/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and the clinical record and interview with staff, it was determined that the facility failed to provide care and treatment as ordered for two of four residents with foley catheters reviewed (Resident R66, R106). Findings include: A review of the facility policy, Consulting Physician/Practitioner Orders dated 10/17/22, last reviewed 1/6/23, indicated for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will call the attending physician to verify the order, document the verification order by entering the order and the time, date, and signature in the electronic health record, and follow facility procedures for verbal or telephone orders including, nothing the order, submitting to pharmacy, and transcribing medication or treatment admiration record. A review of the facility policy, Indwelling Catheter Use and Removal dated 10/17/22, last reviewed 1/6/23, indicated it is the policy of the facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice. A review of the clinical record indicated Resident R66 was admitted to the facility on [DATE], with diagnoses that included hemiparesis following cerebral infraction (partial weakness secondary to an area of brain that dies due to lack of blood flow, muscle weakness and dysphagia (difficulty swallowing). A review of Resident R66's quarterly MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 9/29/23, indicated the diagnosis remained current. A review of clinical physician orders last order review 10/17/23, indicated to change supra pubic foley catheter every shift, no valid diagosis indicated on active physician order. During an interview on 10/20/23, at 10:23 a.m. the Director of Nursing confirmed the lack of valid diagosis for catheter on Resident's R66 physician's orders. A review Resident R106 Minimum Data Set (MDS, mandated assessments of a resident's abilities and care needs) dated 8/8/23 indicated he was admitted to the facility on [DATE], with diagnoses that included stroke (occurs when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients.), and Non-Alzheimer's Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities.) Review of Resident R106's physician order dated 6/13/23, indicated the resident has a 18fr 10cc foley catheter for obstructive uropathy (a condition of excess urine accumulation in kidney(s) that causes swelling of kidneys. This causes pain during urination, nausea and vomiting.) The order failed to indicate when to change the resident's foley catheter. Review of Resident R106's care plan dated 9/27/23, indicated the resident will follow up with urology as ordered and staff will attempt voiding trail per order. It was indicated staff will observe 395684 Page 4 of 10 395684 10/20/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

F 0690 resident for signs and symptoms of infections and report. Level of Harm - Minimal harm or potential for actual harm Review of the Consultation Sheet dated 8/10/23, indicated Resident R106 foley was inserted on 7/19/23, and the doctor will speak with nursing staff at the facility to assess the patient's status to determine if an appointment for a repeat voiding trial is needed or to maintain the chronic foley. Residents Affected - Few Review of the Independence Health System Urologic Associates faxed order dated 8/10/23, indicated to change the residents foley monthly starting 8/17/23. Review of Resident R106's physician orders failed to include an order to change the resident's foley on 8/17/23, then monthly. Review of Resident R106's August 2023 Treatment Administration Record (TAR) failed to include documentation that Resident R106's foley catheter was changed. Review of Resident R106's September 2023 TAR failed to include documentation that Resident R106's foley catheter was changed. Review of Resident R106's October 2023 TAR failed to include documentation that Resident R106's foley catheter was changed. During an observation on 10/18/23, at 11:13 a.m. Resident R106's foley catheter was observed to have sediment in tubing. Resident R106's visitor that was present, indicated the resident didn't have a great day at therapy and is usually able to complete the physical therapy exercises without any issues. During an interview on 10/18/23, at 11:16 a.m. Resident R106's daughter stated she was unsure when the last time her father's foley catheter was changed, however he last seen the Urologist in August. During an interview on 10/18/23, Licensed Practical Nurse (LPN), Employee E6 stated Resident R106 has had his foley in since admission and the last time urology attempted to remove the foley, the resident had difficulty urinating and the decision was made to leave it in. LPN, Employee E6 stated it is the nurses responsible for completing catheter changes. LPN, Employee E6 stated Resident R106 foley catheter should be changed monthly, then as needed if it is or leaking. During an interview on 10/18/23, at 12:13 p.m. the Director of Nursing (DON), confirmed the order that was faxed from Urology to change Resident R106's foley catheter on 8/17/23, and monthly for September and October was not completed or entered into the electronic medical record. During an interview on 10/18/23 at 12:48 p.m., the DON and Nursing Home Administrator (NHA) confirmed that the facility failed to provide care and treatment as ordered for two of four residents with foley catheters reviewed. (Resident R106). 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights. 395684 Page 5 of 10 395684 10/20/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

F 0690 28 Pa. Code 211.10(c)(d) Resident Care Policies. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Residents Affected - Few 395684 Page 6 of 10 395684 10/20/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on review of personnel files and staff interview, it was determined that the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of five Employees reviewed (Nurse Aide, Employee E5). Findings Include: Review of Nurse Aide (NA), Employee E5 personnel file indicated he was hired on 5/15/23, as a non-certified nursing assistant. Review of NA, Employee E5's personnel file indicated he completed the Nurse Aide Training program on 6/8/23. A further review indicated NA, Employee E5 failed the Nurse Aide Written exam on 10/5/23. Review of the facility Deployment Sheets dated 10/7/23, indicated NA, Employee E5 worked 2:00 p.m. until 10:30 p.m. Review of the facility Deployment Sheets dated 10/10/23, indicated NA, Employee E5 worked 10:00 p.m. until 6:30 a.m. Review of the facility Deployment Sheets dated 10/11/23, indicated NA, Employee E5 worked 10:00 p.m. until 2:00 a.m. During an interview on 10/20/23, at 9:01 a.m., the Nursing Home Administrator (NHA) stated NA, Employee E5 had until 10/6/23, 120 days from when he completed the Nurse Aide training course, to become a certified nursing assistant. During an interview on 10/20/23, at 11:51 a.m.,the NHA confirmed the facility failed to ensure the facility does not utilize nurse aides for more than four months for one of five Nurse Aides (NA, Employee E5). 28 Pa. Code 201.14(a)(c) Responsibility of Licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.19 Personnel policies and procedures 395684 Page 7 of 10 395684 10/20/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for two out of five personnel files (Nurse Aide Employee E2 and E3). Residents Affected - Few Findings include: Review of Nurse aide, Employee E2's personnel record indicated she was hired on 1/1/16. Review of Nurse aide, Employee E2's personnel record indicated an annual performance evaluation for the year 2022, was completed on 5/2/22. A further review of Nurse aide, Employee E2's personnel record indicated the facility failed to complete a performance evaluation within 12 months. Nurse aide, Employee E2 performance evaluation for the year 2023, was completed on 9/1/23. Review of Nurse aide Employee E3 personnel record indicated she was hired on 10/24/94. Review of Nurse aide, Employee E3's personnel record indicated an annual performance evaluation for the year 2022, was completed on 6/5/22. A further review of Nurse aide, Employee E3's personnel record indicated the facility failed to complete a performance evaluation within 12 months. Review of Nurse aide Employee E3's personnel record did not include an annual performance evaluation for the year 2023. During an interview on 10/20/23, at 11:51 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to complete annual performance evaluations as required for Nurse aide Employee E2 and Nurse aide Employee E3. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 395684 Page 8 of 10 395684 10/20/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on facility policy, observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the dish room which created the potential for cross contamination. (Main Kitchen) Findings include: Review of facility policy Sanitation Inspection dated 1/6/23, indicated all food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. During an observation of dish room on 10/18/23, at 1:15 p.m. it was revealed area above clean side of dish machine area had a build up of a black substance, dirt and grime in the main kitchen. During an interview on 10/18/23, at 1:30 p.m. the Corporate Food Service Employee E7 confirmed the brown substance in dish room and it has not been confirming the potential for cross contamination and food borne illness. 28 Pa Code: 201.14(a) Responsibility of licensee. 395684 Page 9 of 10 395684 10/20/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review of facility policy, personnel files and staff interview it was determined that the facility failed to ensure the minimum 12 hours of nurse aide training per year and annual training on dementia management for one out of five nurse aide personnel files were completed (Nurse aide, Employee E4). Findings include: The facility Nurse Aide job description last reviewed 1/6/23, indicated that the nurse aide provides each assigned resident with routine individualized nursing care in accordance with state and federal regulations, and accreditation standards. Review of Nurse Aide, Employee E4's personnel record indicated he was hired on 8/15/11. Review of Nurse Aide, Employee E4's personnel record did not include an annual in-service training on dementia and abuse prevention training. A further reviewed of Nurse Aide, Employee E4's personnel record failed to include a minimum of 12 hours of nurse aide training per year as required under §483.95(g)(1). During an interview on 10/20/23, at 11:51 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure Nurse Aide, Employee E4 completed a minimum of 12 hours of nurse aide training per year and annual training on dementia management and abuse as required for one out of five nurse aide personnel files as required (Nurse Aide, Employee E4.) 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.20 (a) (c) Staff development 28 Pa. Code 201.29 (d) Resident rights 395684 Page 10 of 10