Health inspection·October 26, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility neglected to provide the appropriate device to prevent a fall while staff was transporting a resident in a wheelchair, that resulted in actual harm of a head injury for one of four residents (Resident R1). Findings include: Review of the facility Abuse, Neglect, and Exploitation policy dated 10/17/22, indicated it is the facility policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Review of the facility Safe resident handling/Transfers policy dated 10/17/22, last reviewed 12/31/22, indicated it is the facility policy to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the residents. Review of the Nurse Aide (NA) Job Description undated, indicated the certified nurse aide assists by providing direct resident care related to activities of daily living, including ambulating, transferring, and turning and reposition. Review of the Neighborhood Assistant job description dated 9/22/21, indicated the neighborhood assistant provides dining assistance and performs activities with residents, outside of mealtimes, and appropriately documents resident's participation. It was indicated the neighborhood assistant commits to ethical standards and complies with code of conduct, state and federal regulations, accreditation standards, and the facility's policies and procedures. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 9/15/23, revealed diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and anemia (a deficiency of healthy red blood cells in blood.). Section G: Functional Status indicated Resident R1 utilized a wheelchair for mobility. Review of the SBAR Event facility documentation dated 10/12/23, at 6:15 p.m. entered by RN, Employee E6 indicated Neighborhood Assistant, Employee E1 assisted Resident R1 in her wheelchair without leg rests. Resident R1 was unable to hold her foot up and her leg went under the wheelchair, and she Page 1 of 10 396026 396026 10/26/2023 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

F 0600 Level of Harm - Actual harm Residents Affected - Few fell forward and hit her head on the floor face first. It was documented that possible and/or actual contributing factors include unsafe transfer techniques. It was indicated the resident sustained a hematoma to the left side of her head. Recommendations included to reeducate staff about leg rest use. Review of the facility's incident report dated 10/12/23, for Resident R1 indicated the resident sustained a hematoma (solid swelling of clotted blood within the tissues) to the top of her scalp from being pushed in wheelchair without leg rests. Review of a physician's note signed 10/12/23, at 5:40 p.m. indicated Resident R1 was evaluated via video call for a fall with injury. The note stated, the resident had a fall with injury and had a small hematoma on the left side of scalp. The note further indicated to monitor with neurological checks (assess an individual's neurological functions, motor and sensory response, and level of consciousness) per protocol and notify the physician of any changes in condition. Review of a physician's order dated 10/12/23, indicated to transfer Resident R1 to the hospital for evaluation from fall for evaluation. Review of Neighborhood Assistant, Employee E5's witness statement dated 10/13/23, indicated the DON and NHA called Employee E5 at home to obtain a statement. It was indicated Neighborhood Assistant Employee E5 noticed Resident R1's call light cord was out of the wall and noticed Resident R1 was wheeling toward the door with the call light tangled around her wheelchair. It was indicated that Resident R1 asked Neighborhood Assistant, Employee E5 to take her to an activity. As she pushed her, Resident R1 fell forward in the chair. When the DON asked Neighborhood Assistant, Employee E5 was she aware she was not supposed to push people in wheelchairs, she responded, yes. When the DON asked Neighborhood Assistant, Employee E5 if she was aware that she shouldn't transport people without leg rests, she responded yes. Review of Resident R1's witness statement dated 10/13/23, stated she had the call light wrapped and tangled in her wheelchair and couldn't get out of the room. It was indicated Neighborhood Assistant, Employee E5 helped her get the call light untangled from her wheelchair and she asked her to push her. She stated as Neighborhood Assistant, Employee E5 was pushing her down the hall and she fell out of the chair. She stated her leg got caught under the chair. She stated she felt fine at first, but later got a headache and was sent to the hospital. Review of NA, Employee E7's witness statement dated 10/13/23, stated Neighborhood Assistant, Employee E5 was in the nutrition center and indicated that the call light system was pulled from the wall in Resident R1's room. It was indicated Neighborhood Assistant, Employee E5 went to untangle the call light from the resident and assisted her out of the room to activities. It was stated she was pushing her without leg rests and the resident was witnessed to throw her body forward out of chair. NA, Employee E7 indicated she witnessed the resident fall face forward onto the floor. The resident was transported back to bed and later in the shift the resident was transported to the hospital. Review of RN, Employee E6's witness statement dated 10/13/23, stated Resident R1 was in her room preparing to attend activities on the unit. It was indicated the resident was on the far side of room and had call light wrapped around wheelchair causing the call light to unplug from the wall. Neighborhood Assistant, Employee E5 untangled the call light from the wheelchair and proceeded to assist resident to activities. The resident was pushed without leg rests. The resident was holding her legs up at first and then her leg got trapped underneath of the wheelchair causing the resident to 396026 Page 2 of 10 396026 10/26/2023 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

F 0600 Level of Harm - Actual harm Residents Affected - Few catapult out of chair. RN, Employee E6 witnessed the resident fall face forward onto the floor and stated she was unable to prevent fall, and at time of the fall the resident was noted to have been leaning on the right side of the chair and slightly forward. The resident was immediately assessed for injury and a small hematoma (a solid swelling of clotted blood within the tissues) was noted to the left side of her head. The physician was contacted, and a video call was completed. Orders for neurological checks and a physical therapy and occupational consult for wheelchair positioning were obtained. Later the resident complained of a headache and was sent out for further evaluation. Review of Resident R1's census report indicated the resident was on a hospital leave on 10/12/23 and returned to the facility on [DATE]. Review of Resident R1's hospital discharge record dated 10/12/23, indicated Resident R1 sustained a left lateral scalp soft tissue swelling and hematoma following a fall. No new orders were received, the resident was to follow-up with her physician. During an interview on 10/26/23, at 10:44 a.m. Registered Nurse (RN), Employee E1 stated leg rests must always be applied when transporting a resident on and off the unit. It was indicated if a resident can self-propel in the wheelchair, leg rests are not needed. RN, Employee E1 stated if the leg rests were removed, they must be placed back on prior to moving the resident. It was stated everyone knows that leg rests are always needed when pushing someone around, and we also educate families on use of leg rests. During an interview on 10/26/23, at 10:49 a.m. Nurse Aide (NA), Employee E2 stated leg rests are used anytime a resident is transported in a wheelchair. If leg rests are not on the wheelchair, it was stated staff should assess the room, however they are typically kept on the back of the chair in a pouch. During an interview on 10/26/23, at 10:59 a.m. NA, Employee E3 stated legs rest must be on at all times when a resident is pushed in a wheelchair. During an interview on 10/26/23, at 11:01 a.m. RN, Employee E4 stated legs rests must be applied to a resident's wheelchair before they are moved. During an interview on 10/26/23, at 11:07 a.m. Neighborhood Assistant, Employee E5 stated the call alert system was beeping and it indicated Resident R1's call bell cord was out of the wall. When Neighborhood Assistant, Employee E5 went to see what was going on, she indicated Resident R1 was sitting in the doorway in her wheelchair trying to get out. She stated she didn't realize the call bell was wrapped around her wheelchair, so she unwrapped it and plugged it back in the wall. It was indicated Resident R1 asked Neighborhood Assistant, Employee E5 to take her down the hallway. Neighborhood assistant, Employee E5 stated she forgot to look down, I just assumed, I didn't even think to look down and as she was pushing her down the hallway, Resident R1 fell out of the chair and hit her face on the floor. Neighborhood Assistant, Employee E5 stated she was active on the Nurse Aide Registry and sometime in September, she was told she had to either become Certified Nurse Aide or shower aide. During an interview on 10/26/23, at 11:45 a.m. RN, Employee E6 stated she seen Neighborhood Assistant, Employee E1 was pushing Resident R1 down the hall without leg rests. It was indicated the resident was holding her legs ups, then one of her legs dropped and she fell forward hitting her face first. RN, Employee E6 stated she immediately went to assess the resident and called a physician on video call. She stated the resident sustained a hematoma to the left side of her head and originally had 396026 Page 3 of 10 396026 10/26/2023 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

F 0600 Level of Harm - Actual harm no complaints. It was indicated the doctor ordered the resident to stay in the facility and to perform neurological checks as protocol and contact a physician if Resident R1 had a change in condition. RN, Employee E6 stated shortly after the resident complained of increased head pain and was sent to the emergency room for further evaluation. Residents Affected - Few Review of Neighborhood Assistant, Employee E5 employee file indicated, Neighborhood Assistant, Employee E5 was hired as a Neighborhood Assistant on 9/22/21. The job description for a Neighborhood Assistant was signed on 9/22/21. A further review of the employee's file failed to reveal a Nurse Aide job description signed and dated. During an interview on 10/26/23, at 11:20 a.m. with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON), it was indicated Neighborhood Assistant, Employee E5 should have not pushed Resident R1 in her wheelchair because she is light duty. The NHA confirmed Neighborhood Assistant, Employee E1 pushed Resident R1 without leg rests which caused the resident to fall forward and sustain a head injury and had to be sent to the hospital for further evaluation. The NHA stated Neighborhood Assistant, Employee E5 had an active nurse aide license and assisted staff by helping shower residents. It was stated if a resident could walk to the shower, Neighborhood Assistant, Employee E5 may walk with them, however if they were in a wheelchair, she had to have another staff member transport. During an interview on 10/26/23, at 1:30 p.m. the Nursing Home Administrator and Assistant Director of Nursing confirmed that the facility neglected to provide leg rest for Resident R1 to prevent a fall while staff was transporting in a wheelchair, which resulted in actual harm of a head injury to Resident R1. 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a )(c)(d) Resident Rights 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services 396026 Page 4 of 10 396026 10/26/2023 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

F 0610 Respond appropriately to all alleged violations. 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, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for one of four residents reviewed (Resident CR1). Residents Affected - Few Findings include: A review of the facility's Abuse, Neglect, and Exploitation policy dated 10/17/22, last reviewed 12/31/22 indicated an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. It states physical injury of a resident of unknown source is a possible indicator of abuse. It was indicated the facility must identify and interview all persons, including alleged victim, alleged perpetrator, witnesses and other who might have knowledge of the allegations. It was indicated complete and thorough documentation of the investigation must be provided. Review of the facility's Incidents and Accidents policy dated 10/17/22, last reviewed 12/31/22, indicated it is the facility's policy to utilize the risk management module to report, investigate, and review any accidents or incidents that occur, on facility property and may involve or allegedly involve a resident. It stated if an incident/accident was witnessed by other people the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director and/or Administrator. Review of the facility Dementia Care policy, dated 10/17/22, last reviewed 12/31/22, indicated it is the facility policy to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practical physical, mental, and psychosocial well-being. Review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and anxiety. The resident was discharged on 10/23/23. Review of the facility incident and accident list dated 10/26/23, indicated Resident CR1 had an injury on 10/18/23. Review of Resident CR1's incident report dated 10/18/23, indicated the resident had a bruise to the left side of the abdomen. It was indicated the Director of Nursing and wound care nurse, and administration were notified. It stated the resident wasn't aware of bruise on abdomen. In the notes section it was documented that the resident was taken to bathroom and a large bruise was noticed to her left side of her abdomen. The resident was interviewed and stated she didn ' t know how she got it. A further review of Resident CR1's investigation report failed to include witness statements signed from the resident, staff member who took resident to the bathroom and identified the bruise, and any other possible witnesses who had contact with the resident during the period of the alleged incident. During an interview on 10/26/23, at 11:20 a.m., the Nursing Home Administrator and Assistant Director of nursing confirmed that the facility failed to fully investigate injuries of unknown origin for Resident CR1. 396026 Page 5 of 10 396026 10/26/2023 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

F 0610 28 Pa. Code: 201.14 (a) Responsibility of licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.14 (c)(e) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management. Residents Affected - Few 396026 Page 6 of 10 396026 10/26/2023 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls, resulting in actual harm of a head injury for one of four residents reviewed (Resident R1). Findings include: Review of the facility Safe resident handling/Transfers policy dated 10/17/22, last reviewed 12/31/22, indicated it is the facility policy to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the residents. Review of the Nurse Aide (NA) Job Description undated, indicated the certified nurse aide assists by providing direct resident care related to activities of daily living, including ambulating, transferring, and turning and reposition. Review of the Neighborhood Assistant job description dated 9/22/21, indicated the neighborhood assistant provides dining assistance and performs activities with residents, outside of mealtimes, and appropriately documents resident's participation. It was indicated the neighborhood assistant commits to ethical standards and complies with code of conduct, state and federal regulations, accreditation standards, and the facility's policies and procedures. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 9/15/23, revealed diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and anemia (a deficiency of healthy red blood cells in blood.). Section G: Functional Status indicated Resident R1 utilized a wheelchair for mobility. Review of the SBAR Event facility documentation dated 10/12/23, at 6:15 p.m. entered by RN, Employee E6 indicated Neighborhood Assistant, Employee E1 assisted Resident R1 in her wheelchair without leg rests. Resident R1 was unable to hold her foot up and her leg went under the wheelchair, and she fell forward and hit her head on the floor face first. It was documented that possible and/or actual contributing factors include unsafe transfer techniques. It was indicated the resident sustained a hematoma to the left side of her head. Recommendations included to reeducate staff about leg rest use. Review of the facility's incident report dated 10/12/23, for Resident R1 indicated the resident sustained a hematoma (a solid swelling of clotted blood within the tissues) to the top of her scalp from being pushed in wheelchair without leg rests. Review of a physician's note dated 10/12/23, at 5:40 p.m. indicated Resident R1 was evaluated via video call for a fall with injury. The note stated, the resident had a fall with injury and had a small hematoma on the left side of scalp. The note further indicated to monitor with neurological checks (assess an individual ' s neurological functions, motor and sensory response, and level of consciousness) per protocol and notify the physician of any changes in condition. 396026 Page 7 of 10 396026 10/26/2023 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of a physician's order dated 10/12/23, at 7:11 p.m. indicated to transfer Resident R1 to the hospital for evaluation from a fall. A review of the resident's clinical record failed to include documentation of the change in condition that occurred. Review of Resident R1's witness statement dated 10/13/23, stated she had the call light wrapped and tangled in her wheelchair and couldn't get out of the room. It was indicated Neighborhood Assistant, Employee E5 helped her get the call light untangled from her wheelchair and she asked her to push her. She stated as Neighborhood Assistant, Employee E5 was pushing her down the hall, she fell out of the chair. She stated her leg got caught under the chair. She stated she felt fine at first, but later got a headache and was sent to the hospital. Review of NA, Employee E7's witness statement dated 10/13/23, stated Neighborhood Assistant, Employee E5 was in the nutrition center and indicated that the call light system was pulled from the wall in Resident R1's room. It was indicated Neighborhood Assistant, Employee E5 went to untangle the call light from the resident and assisted her out of the room to activities. It was stated she was pushing her without leg rests and the resident was witnessed to throw her body forward out of chair. NA, Employee E7 indicated she witnessed the resident fall face forward onto the floor. The resident was transported back to bed and later in the shift the resident was transported to the hospital. Review of RN, Employee E6's witness statement dated 10/13/23, stated Resident R1 was in her room preparing to attend activities on the unit. It was indicated the resident was on the far side of room and had call light wrapped around wheelchair causing the call light to unplug from the wall. Neighborhood Assistant, Employee E5 untangled the call light from the wheelchair and proceeded to assist resident to activities. The resident was pushed without leg rests. The resident was holding her legs up at first and then her leg got trapped underneath of the wheelchair causing the resident to catapult out of chair. RN, Employee E6 witnessed the resident fall face forward onto the floor and stated she was unable to prevent fall, and at time of the fall the resident was noted to have been leaning on the right side of the chair and slightly forward. The resident was immediately assessed for injury and a small hematoma (a solid swelling of clotted blood within the tissues) was noted to the left side of her head. The physician was contacted, and a video call was completed. Orders for neurological checks and a physical therapy and occupational consult for wheelchair positioning were obtained. Later the resident complained of a headache and was sent out for further evaluation. Review of Resident R1's investigation report dated 10/13/23, indicated the Nursing Home Administrator (NHA) and Director of Nursing (DON) had a discussion with Neighborhood Assistant, Employee E5 regarding the incident that occurred with Resident R1 on 10/12/23. It was documented that Neighborhood Assistant, Employee E5 entered Resident R1's room and found her wheeling toward the door in her wheelchair with the call light on her wheelchair and pulled out of the wall. It was indicated Resident R1 wanted to go to an activity, so Neighborhood Assistant, Employee E5 pushed her in her wheelchair toward the activity and she didn't know what happened, but Resident R1 went forward out of the chair. The witness statement was typed and signed by the NHA. Review of Resident R1's census report indicated the resident was on a hospital leave on 10/12/23 and returned to the facility on [DATE]. Review of Resident R1's hospital discharge record dated 10/12/23, indicated Resident R1 had left lateral scalp soft tissue swelling and hematoma following a fall. No new orders were received, the resident was to follow up with her physician. 396026 Page 8 of 10 396026 10/26/2023 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

F 0689 Level of Harm - Actual harm Residents Affected - Few During an interview on 10/26/23, at 10:44 a.m. Registered Nurse (RN), Employee E1 stated leg rests must always be applied when transporting a resident on and off the unit. It was indicated if a resident can self-propel in the wheelchair, leg rests are not needed. RN, Employee E1 stated if the leg rests were removed, they must be placed back on prior to moving the resident. It was stated everyone knows that leg rests are always needed when pushing someone around, and we also educate families on use of leg rests. During an interview on 10/26/23, at 10:49 a.m. Nurse Aide (NA), Employee E2 stated leg rests are used anytime a resident is transported in a wheelchair. If leg rests are not on the wheelchair, it was stated staff should assess the room, however they are typically kept on the back of the chair in a pouch. During an interview on 10/26/23, at 10:59 a.m. NA, Employee E3 stated legs rest must be on at all times when a resident is pushed in a wheelchair. During an interview on 10/26/23, at 11:01 a.m. RN, Employee E4 stated legs rests must be applied to a resident's wheelchair before they are moved. During an interview on 10/26/23, at 11:07 a.m. Neighborhood Assistant, Employee E5 stated the call alert system was beeping and it indicated Resident R1's call bell cord was out of the wall. When Neighborhood Assistant, Employee E5 went to see what was going on, she indicated Resident R1 was sitting in the doorway in her wheelchair trying to get out. She stated she didn't realize the call bell was wrapped around her wheelchair, so she unwrapped it and plugged it back in the wall. It was indicated Resident R1 asked Neighborhood Assistant, Employee E5 to take her down the hallway. Neighborhood assistant, Employee E5 stated she forgot to look down, I just assumed, I didn't even think to look down and as she was pushing her down the hallway she fell out of the chair and hit her face on the floor. Neighborhood Assistant, Employee E5 stated she was active on the Nurse Aide registry, and sometime in September, she was told she had to either become Certified Nurse Aide or shower aide, however she did not complete any retraining. During an interview on 10/26/23, at 11:45 a.m. RN, Employee E6 stated she seen Neighborhood Assistant, Employee E1 was pushing Resident R1 down the hall without leg rests. It was indicated the resident was holding her legs ups, then one of her legs dropped and she fell forward hitting her face first. RN, Employee E6 stated she immediately went to assess the resident and called a physician on video call. She stated the resident sustained a hematoma to the left side of her head and originally had no complaints. It was indicated the doctor ordered the resident to stay in the facility and to perform neurological checks as protocol and contact a physician if Resident R1 had a change in condition. RN, Employee E6 stated shortly after the resident complained of increased head pain and was sent to the emergency room for further evaluation. Review of Neighborhood Assistant, Employee E5 employee file indicated, Neighborhood Assistant, Employee E5 was hired as a Neighborhood Assistant on 9/22/21. The job description for a Neighborhood Assistant was signed on 9/22/21. A further review of the employee's file failed to reveal a Nurse Aide job description signed and dated. During an interview on 10/26/23, at 11:20 a.m. the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON), Employee E8 indicated Neighborhood Assistant, Employee E5 should have not pushed Resident R1 in her wheelchair because she is light duty. The NHA confirmed Neighborhood Assistant, Employee E1 pushed Resident R1 without leg rests which caused the resident to fall forward 396026 Page 9 of 10 396026 10/26/2023 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

F 0689 Level of Harm - Actual harm and sustain a head injury and had to be sent to the hospital for further evaluation. The NHA stated Neighborhood Assistant, Employee E5 had an active nurse aide license and assisted staff by helping shower residents. It was stated if a resident could walk to the shower, Neighborhood Assistant, Employee E5 may walk with them, however if they were in a wheelchair, she had to have another staff member do it. Residents Affected - Few During an interview on 10/26/23, at 1:30 p.m. the Nursing Home Administrator and Assistant Director of Nursing confirmed that the facility failed to provide appropriate supervision and devices to prevent falls, resulting in actual harm of a head injury for Resident R1. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a)(c)(d) Resident rights 396026 Page 10 of 10