Health inspection·December 30, 2025

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 record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to assess a resident after a fall for one of four residents (Resident R1). Findings include: Review of the facility Certified Nursing Assistant job description indicated The Certified Nursing Assistant assists the licensed nursing staff by providing direct resident care related to activities of daily living. Communicates observations and findings to the Charge Nurse. Review of the facility policy Incident and Accidents last reviewed 1/2/25, indicated injuries will be assesses by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. Review of Employee counseling reports dated 11/17/25, indicated two Nurse Aids (NA) were re-educated on residents that have a fall will require an evaluation from a Registered Nurse (RN) prior to assisting that resident into a bed or chair. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (the heart doesn't pump the way it should) and obstructive uropathy (restricts flow of urine). Interview completed on 12/20/25, at 11:25 a.m. upon asking Resident R1 concerning a fall that occurred in November he stated I was getting ready for bed, I used a walker, I stood up grabbed my walker went to pivot and I just kind of slumped down, the aid was by me, I went down slow not hard, just slowly on my left side she made sure I was alright and went and got another aide they used the lift to get me back in bed. Review of facility investigative report and nursing notes on 12/20/25, indicated Resident R1 had a fall on 11/15/25, Resident R1 was returned to bed utilizing a mechanical lift by two NA's the notes failed to include notification to the Registered Nurse (RN) or practitioner for assessment of injury prior to returning Resident R1 to bed. Interview completed on 12/30/25, at 12:40 p.m. the Director of Nursing confirmed that the facility failed to make certain that residents were provided appropriate treatment and care by failing to assess a resident after a fall for one of four residents (Resident R1). 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident Care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services. Residents Affected - Few Page 1 of 2 396026 396026 12/30/2025 Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

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 facility policy, clinical record review, and interview, the facility failed to have a physician order and care plan with specifications relating to size of suprapubic catheter (a thin, flexible tube inserted into the bladder through a small hole in the lower belly to drain urine) and balloon inflation amount (secures catheter to bladder) for one of three residents (Resident R1).Findings include: Review of the facility policy Indwelling Catheter Use and Removal last reviewed 1/2/25, indicated the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (the heart doesn't pump the way it should) and obstructive uropathy (restricts flow of urine). Section H0100 indicated indwelling foley catheter use. Review of Resident R1's physician order dated 9/30/25, indicated to change suprapubic catheter every four weeks the order failed to include specifications for size and balloon inflation amount for the suprapubic catheter. Review of Resident R1's care plan with revision on 12/18/25, indicated suprapubic catheter use and failed to include specifications for size and balloon inflation amount for the suprapubic catheter. Interview completed on 12/30/25, the Director of nursing confirmed the facility failed to have a physician order and care plan with specifications relating to size of suprapubic catheter and balloon inflation amount for one of three residents (Resident R1). 28 Pa. Code 201. 18(b)(1) Management.28 Pa code:211.10(c)(d) Resident care policies.28 Pa Code:211.12(c)(d)(1)(2)(5) Nursing services . 396026 Page 2 of 2