Health inspection·June 30, 2023

F 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Minimal harm or potential for actual harm Based on observations and resident and staff interviews it was determined that the facility failed to ensure that residents were informed of all their rights, rules, regulations and responsibilities for one of six residents reviewed (Resident R95). Residents Affected - Some Findings include: During observations on 6/28/23, 11:30 a.m., and 6/29/23, 9:19 a.m., observations were made on the first and second floors of the facility of postings. The postings failed to contain information/contact information regarding Medicaid /Medicare. During an interview on 6/28/23, at 11:00 a.m. Resident R95 indicated that they were unaware of Medicare/Medicaid, benefits and the facility had not discussed this as possible assistance for the resident. During an interview on 6/30/23, at 3:13 p.m. Nursing Home Administrator confirmed that the facility failed to post information about Medicaid/Medicare, and did not discuss with Resident R95 the Medicaid/Medicare programs as possible assistance. 28 Pa. Code 201.29 e Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Rebecca Residence 3746 Cedar Ridge Road Allison Park, PA 15101 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0660 Plan the resident's discharge to meet the resident's goals and needs. 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, resident and staff interviews it was determined that the facility failed to provide discharge planning for resident needs prior to discharge for one of three residents (Resident R95). Residents Affected - Few Findings include: Resident R95 was admitted to the facility on [DATE], with the following diagnosis: presence of artificial ankle joint (replacement of a damaged ankle joint with an artificial implant), tear of lateral meniscus left knee (an injury to the semi-circular cartilage on the outside of the knee joint), other tear of medial meniscus (injury to the cartilage tissue that is located on the inside of the knee), and diabetes mellitus ( a group of diseases that result in too much sugar in the blood). During an interview on 6/28/23, at 10:49 a.m. Resident R95 indicated the following: that discharge is happening this week, Resident R95 stated that they did not think they were ready to be discharged as they were having difficulty walking independently without falling. Resident R95 indicated that they were discharging home or to a friend's house, but they had made those plans with their friend the facility did not assist. Resident R95 did not recall receiving a discharge plan, nor any referrals to services in the community to assist with after discharge, from the facility. Resident R95 fell (6/25/23) while trying to stand up from bed independently (while using wheeled walker) as they would have to do to become discharged and be able to care for self. Resident R95 has not walked independently since admit, the leg where the meniscus was torn, buckles and there is no warning for this and causes Resident R95 to fall to the ground. Resident R95 lives on their own, in a small apartment and cannot fit a lot of equipment in the apartment. Resident R95 stated that they currently have insurance from their employment, but without full use of both legs they would not be able to keep that insurance (due to not being able to go back to work). Resident R95 also indicated that the facility did not assist with finding any different insurance, or with applying for any type of assistance. Review of clinical notes 6/20/23, Resident R95 expressed a concern over his/her insurance stopping due to being unable to work (6/20/23). During an interview on 6/28/23, between 1:38 p.m. and 2:17 p.m. with the Discharge Planner Employee E1 was asked to show the discharge plan - Discharge planner Employee E1 provided three clinical notes that documented conversations with Resident R95 but failed to show that Resident R95 was provided with a discharge plan and or made aware that this was their discharge planning. During an interview on 6/28/23, at 2:17 p.m., Director of Rehabilitation Employee E2 the following was confirmed - that they walked with Resident R95, but Resident R95 did not walk independently. During an interview on 6/30/23, at 3:13 p.m. Nursing Home Administrator confirmed that the facility failed to provide discharge planning for resident needs prior to discharge form the facility. 28 Pa. Code 211.11(d)e Resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Rebecca Residence 3746 Cedar Ridge Road Allison Park, PA 15101 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, resident observations and interviews, clinical record review and staff interviews, it was determined that the facility failed to make certain that residents had complete and consistent physician orders and care plan development for use of a CPAP machine (continuous airway pressure/bi-level positive airway pressure, devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle) and/or oxygen therapy for three of five residents (Resident R4, R24, and R158). Residents Affected - Some Findings include: Review of the facility policy Noninvasive Ventilation (CPAP, BiPAP, Trilogy) dated 2/3/23, indicated the facility will provide noninvasive ventilation per physician ' s orders and current standards of practice. The Resident Assessment Instrument (RAI) User Manual, which gives instructions for completing Minimum Data Set assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that Section O: Special Treatments, Procedures, and Programs, Question O0100G, Non-invasive Mechanical Ventilator (BiPAP/CPAP) should be checked if the resident utilized a BiPAP or CPAP after admission/entry or reentry to the facility and within the 14-day look-back period. Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/17/23, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), respiratory failure with hypoxia (condition where the body doesn't have enough oxygen in the tissues), and obstructive sleep apnea (disorder that causes breathing to repeatedly stop and start during sleep). Section O: Special Treatments, Procedures, and Programs, Question O0100G, Non-invasive Mechanical Ventilator (BiPAP/CPAP) indicated CPAP usage. Review of Resident R4 ' s current physician orders as of 6/28/23, did not include an order to provide CPAP services that included the type of equipment and settings, administration time, humidification, and monitoring for complications if needed. Review of Resident R4 ' s baseline care plan initiated 6/16/23, failed to include goals and interventions related to CPAP usage. Review of the clinical record indicated that Resident R24 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], indicated diagnoses of heart failure , respiratory failure with hypoxia (condition where the body doesn't have enough oxygen in the tissues), and obstructive sleep apnea. Section O: Special Treatments, Procedures, and Programs, Question O0100C, Oxygen indicated oxygen therapy usage. Review of Resident R24 ' s physician orders dated 6/10/23, indicated that Resident R24 was to receive oxygen at five liters per minute every shift, that the night nurse is to check weekly the if the oxygen filter is cleaned, and tubing and humidifier changed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Rebecca Residence 3746 Cedar Ridge Road Allison Park, PA 15101 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident R24 ' s current care plan reviewed on 6/29/23, failed to include goals and interventions related to oxygen usage. Review of the clinical record indicated that Resident R158 was admitted to the facility on [DATE]. Review of Resident R158's diagnosis list indicated diagnoses of heart failure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and obstructive sleep apnea. Review of hospital discharge paperwork dated 4/27/23, included in the referral from Resident R158's previous nursing care facility, indicated that Resident R158 used a CPAP machine. Review of Resident R158's baseline care plan dated 6/13/23, failed to include CPAP usage. Review of Resident R158's comprehensive care plan dated 6/15/23, indicated CPAP therapy for obstructive sleep apnea. Review of Resident R158's progress notes dated 6/14/23, through discharge on [DATE], include five mentions of constant CPAP usage for sleep apnea. Review of Resident R158 ' s current physician orders as of 6/28/23, did not include an order to provide CPAP services that included the type of equipment and settings, administration time, humidification, and monitoring for complications if needed. During an interview on 6/30/23, at 4:00 p.m. the Director of Nursing confirmed that the facility failed to make certain that residents had complete and consistent physician orders and care plan development for use of a CPAP machine and/or oxygen therapy for three of five residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Rebecca Residence 3746 Cedar Ridge Road Allison Park, PA 15101 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 documents and staff interview it was determined that the facility failed provide in-service education based on the outcome of the performance review for one of five Nurse Aides (NA) (Nurse Aide Employee E6). Residents Affected - Few Findings include: Review of the facility provided list of current employees indicated NA Employee E6 was hired on 4/26/19. Review of NA Employee E6's performance review document (undated), indicated that improvement was needed on patient safety and the timely completion of mandatory inservice trainings. Review of NA Employee E6's Learner Transcript (list of all trainings assigned to the employee) provided by the facility on 6/28/23, failed to include any trainings for NA Employee E6 from the dates of 4/26/22, through 4/26/23. The most recent training was dated 2/10/22. During an interview on 6/29/23, at 10:00 a.m. the Director of Nursing confirmed that the facility failed provide in-service education based on the outcome of the performance review for one of five nurse aides. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Rebecca Residence 3746 Cedar Ridge Road Allison Park, PA 15101 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 and resident and staff interview it was determined that the facility failed to provide medically related social services to one of six residents reviewed (Resident R95). Residents Affected - Few Findings include: Review of facility documentation job description social worker, indicated that The Social Worker is a professional who provides services to residents at the facility and their families or other responsible parties in accordance with current Federal and State regulations and facility policy and procedure to assure that the psycho-social needs of the residents are met and maintained on an individual basis. Resident R95 was admitted to the facility on [DATE], with the following diagnosis: presence of artificial ankle joint (replacement of a damaged ankle joint with an artificial implant), tear of lateral meniscus left knee (an injury to the semi-circular cartilage on the outside of the knee joint), other tear of medial meniscus (injury to the cartilage tissue that is located on the inside of the knee), and diabetes mellitus ( a group of diseases that result in too much sugar in the blood). During an interview on 6/28/23, at 10:49 a.m. Resident R95 indicated that the insurance that he/she has is through the workplace. Currently Resident R95 is unable to work due to the injuries. Resident R95 stated that the insurance through his/her workplace will be stopped due to Resident R95, not being able to work. Resident R95 shared that the facility did not facility assistance with applying for Medicare/Medicaid or social security disability. Review of the clinical record failed to include any referral/assistance with completing applications for Medicare/Medicaid or social security disability. During an interview on 6/30/23, at 3:13 p.m. Nursing home Administrator confirmed that the facility failed to provide medically related social services to Resident R95. 28 Pa. Code 211.16 (a) Social services. 28 Pa. Code 211.5 (h)Clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Rebecca Residence 3746 Cedar Ridge Road Allison Park, PA 15101 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some Based on review of facility policy, clinical record, and staff interview it was determined that the facility failed to provide a diagnosis for a psychotropic medication for one of five residents (Resident R22) and failed to ensure that alternate interventions were attempted prior to the administration of psychotropic medications for one of five residents (Resident R10). Findings include: Review of facility policy Use of Psychotropic Medication dated 2/3/23, indicated that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record. The policy further indicated that residents who receive psychotropic drugs shall also receive non-pharmacological interventions. Resident R22 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/25/23, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). No neurological, psychiatric, or mood disorders were present on the assessment. Review or Resident R22's diagnoses list in the electronic medical record failed to reveal a neurological, psychiatric, or mood disorders diagnosis. Review of Resident R22's physician orders included an order dated 3/21/23 for buspirone HCl (an anti-depressant medication) 5 milligrams (mg) three times per day, and olanzepine (an anti-psychotic medication) 2.5 mg at bedtime for depression. Resident R10 was admitted [DATE], with the following diagnosis borderline personality disorder (personality disorder characterized by sever mood swings, impulsive behavior, and difficulty forming stable personal relationships) and major depressive disorder (persistently depressed mood or loss of interest in activities). This diagnosis remained current as of the MDS dated [DATE]. Review of Resident R10 physician orders indicated Ativan Tablet 0.5 (Lorazepam) Give 0.5 mg via G-tube every 8 hours as needed for anxiety. Review of MAR (medication administration record) for May 2023 indicated that Resident R10 received Ativan 19 times. Review of MAR for June 2023 indicated that Resident R10 received Ativan 19 times. Review of Resident R10's clinical record failed to include alternative interventions prior to psychotropic medications being administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Rebecca Residence 3746 Cedar Ridge Road Allison Park, PA 15101 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/30/23, at 4:00 Director of Nursing confirmed that the facility failed to provide a diagnosis for a psychotropic medication for one of five residents and failed to ensure that alternate interventions were attempted prior to the administration of psychotropic medications for one of five residents. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Rebecca Residence 3746 Cedar Ridge Road Allison Park, PA 15101 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change for one of four residents (Resident R29). Residents Affected - Few Findings include: Review of the facility policy Hand Hygiene dated 2/3/23, indicated staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. During an observation on 6/29/23, at 10:40 a.m. Licensed Practical Nurse (LPN) Employee E5 donned clean gloves, and began to set up the bedside table in preparation for Resident R29's dressing change. -LPN Employee E5 removed her gloves, put on new gloves, and removed Resident R29's soiled dressing without performing hand hygiene. -After removing the soiled dressing, LPN Employee E5 placed it on the bed linen. -LPN Employee E5 then proceeded to clean Resident R29 ' s wound. -After cleaning the wound, LPN Employee E5 removed her gloves, put on new gloves, and applied the clean dressing without performing hand hygiene. During an interview on 6/29/23, at 10:46 a.m. LPN Employee E5 confirmed that she did not perform hand hygiene in between removing her soiled gloves and reapplying clean gloves. During an interview on 6/29/23, at 11:30 a.m. the Director of Nursing confirmed the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change for one of four residents. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Rebecca Residence 3746 Cedar Ridge Road Allison Park, PA 15101 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of facility documents and staff interview, it was determined that the facility failed to provide training that outlines and informs staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program. Findings include: Review of the facility QAPI/QA Skilled Nursing and Rehabilitation 2023 Compliance Work Plan indicated a facility goal of 100% compliance with staff attendance for all mandatory training. Review of the Skilled Nursing and Personal Care Home 2023 Mandatory In-Service Schedule failed to include training on the QAPI program. During an interview on 6/30/23, at 4:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training that outlines and informs staff of the elements and goals of the facility's QAPI program. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396067 If continuation sheet Page 11 of 11