Concordia At Villa St Joseph

Review of the facility Resident and Family Grievances policy dated 1/1/26, indicated the Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations. A resident or family member may voice grievances with respect to care and treatment that has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay.

Grievances may be voiced in form of verbal complaint to a staff member.

The staff member receiving the grievance will record the nature and specifics of the grievance on the designated form or assist the resident or family member to complete the form.

Forward the grievance form to the Grievance Official as soon as practicable.

Review of the facility's January Resident Council Minutes dated 1/19/26, revealed Resident R142 attended the resident council meeting and expressed a concern related to maintenance. It was indicated when the heater controls are on low, the room gets very hot.

Roommate opens window and Resident R142 is cold.

Difficult to adjust and create a comfortable environment.

During an interview on 3/2/26, at 12:02 p.m.

Resident R142 confirmed she expressed a concern in January's Resident Council meeting regarding room temperatures.

Review of January 2026, facility provided Grievance log failed to include Resident R142 grievance.

Interview on 3/2/26, at 2:12 p.m. the Nursing Home Administrator confirmed that the facility failed to document, resolve, and provide response to resident and/or their responsible party regarding concerns for one of five residents (Resident R142). 28 Pa.

Code 201.14(b) Responsibility of licensee. 28 Pa.

Code 201.18(b)(1)(e)(1) Management. 28 PA Code: 201.29(a) Resident rights.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

28 Pa.

Code: 211.9(a)(1)(d)(k) Pharmacy services.

28 Pa.

Code: 211.12(c)(d)(5) Nursing services.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

Review of the admission record indicated Resident R74 was admitted to the facility on [DATE].

Review of the admission record diagnosis indicated: sciatica left side (nerve pain from injury or irritation to your sciatica nerve), other abnormalities of gait and mobility (gait disorders are an abnormal walking pattern with many possible causes like an injury, sore, an inner ear (balance)issue or nerve damage), and age-related osteoporosis without current pathological fracture(Bones to become weak and brittle so brittle that a fall or even mild stresses such as bending over or coughing can cause a break.

Osteoporosis-related breaks most commonly occur in the hip, wrist or spine).

Review of the facility documentation progress notes dated 3/1/26, indicated: Hospital nurse called at 0005 (5:00 a.m.) to report radiology report of LEFT femur broken.

Resident R74 to be admitted .

Review of the facility documentation indicated that Resident R74 progress notes dated 3/1/26, Pt with history of left side sciatica and inability to ambulate. Pt reports new onset worsening pain to left hip.

Reports she can't move leg.

She is anxious.

She wants to go to hospital.

Review of witness statements indicated Resident R74 was moved into bed by a sit to stand ( a type of transfer device for residents) by Nurse Aide (NA) Employee E10 and afterwards complained of pain.

During an interview on 3/4/26, at 12:55 p.m. NA Employee E10 indicated: I took Resident R74 to the bathroom utilizing the sit to stand lift. I took the resident back to bed with the sit to stand, placed her in the bed, afterwards she complained of pain - I notified the nurse.

Review of facility provided documentation indicated witness statements from staff were completed.

Further review failed to include that the facility identified the injury of unknown origin as potential neglect or that an investigation was completed to rule out neglect.

During an interview on 3/5/26, at 10:46 a.m.

Director of Nursing (DON) indicated that the investigation was completed, and the facility had collected the witness statements but there was no further documentation, nor could documentation be provided to show that neglect was investigated and ruled out.

During an interview on 3/5/26, at 10:50 a.m.

Nursing Home Administrator and DON were informed that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of one of four abuse allegations (Resident R74). 28. Pa Code 201.14(a) Responsibility of licensee.28. Pa Code 201.18(b)(1)(e)(1) Management.28. Pa.

Code 211.12(d)(1)(5) Nursing services.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

the facility failed to conduct a thorough investigation of an injury of unknown origin to eliminate

28 Pa Code: 201.18 (e)(1)(2) Management.

28 Pa Code: 201.29 (a)(c) Resident Rights. 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

Review of the admission record indicated Resident R157 admitted to the facility on [DATE], with diagnoses of depression and diabetes (a condition that causes blood sugar to rise).

Review of Resident R157's physician order dated 2/25/26, indicated to change incisional wound vac every 3 days.

Place versatile or Adaptec or similar dressing, black sponge over the incision.

Set wound vac at 80 mm/hg continuous suction.

Replace knee immobilizer.

Review of Resident R157's care plan dated 2/25/26, revealed the resident had pseudomonas/ candida parasitosis infection to right knee.

Interventions included to apply wound vac as prescribed.

The care plan failed to include the wound vac settings or order to change the wound vac.

During an interview on 3/2/26, at 1:55 p.m.

Licensed Practical Nurse Assessment Coordinator, Employee E7 confirmed the facility failed to ensure Resident R157's baseline care plan included wound vac settings and an order to change the wound vac. 28 Pa Code 211.10(a) Resident care policies.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

During an interview on 3/1/26, at 10:11 a.m.

Resident R157 wound vac was not on and operating.

The

During an interview on 3/2/26, at 10:12 a.m.

Licensed Practical Nurse (LPN), Employee E9 confirmed Resident R157's wound vac was not on and functioning. LPN, Employee E9 confirmed the facility failed to provide the wound vac as ordered.

Interview on 3/4/26, at 11:00 a.m. the Director of Nursing confirmed that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and follow physician orders for three of four residents (Resident R36, R73, R157). 28 Pa.

Code: 201.14(a) Responsibility of Licensee. 28 Pa.

Code: 211.10(d) Resident care policies. 28 Pa.

Code: 211.12 (d)(5) Nursing Services.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

During an interview on 3/5/26, at 2:05 p.m. the Director of Nursing

enteral feeding tube received appropriate treatment and services to prevent potential complications as required for one of three residents (Residents R147). 28 Pa.

Code: 201.18(b)(1) Management. 28 Pa.

Code: 211.10(c) Resident care policies. 28 Pa.

Code: 211.12(d)(1) Nursing services.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

determined that the facility failed to maintain a peripheral intravenous (IV) catheter site consistent

include:

Review of the facility policy Intravenous Therapy dated 1/1/26, indicated the facility will adhere to accepted standards of practice regarding infusion practices. IV sites are checked every shift and as needed for signs and symptoms of infection or inflammation.

Review of the admission record indicated Resident R29 admitted to the facility on [DATE].Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/26, indicated the diagnoses of renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), pneumonia (lung infection) and urinary tract infection.Review of Resident R29's physician order dated 2/28/26, indicated sodium chloride intravenous solution0.9 % (percent).

Use 500 ml (milliliters) intravenously every shift for dehydration. To be run as a 500ml bolus (at once) and then remaining 500 mls at 75 mls/hour for a total of 1000mls.Observation on 3/1/26, at 9:35 a.m.

Resident R29 was lying in bed.

The left lower arm had a peripheral IV inserted.

The site was not labeled with a date or time.

The extension tubing connected to the IV catheter itself was not clamped off, and failed to have a cap, or injection site at the end.

Blood was noted to be backed up in the extension tubing.Observation and interview with Licensed Practical Nurse (LPN) Employee E3 confirmed the appearance of the IV site, that it was not clamped off, failed to have a cap, or injection site at the end, and that blood was noted to be backed up in the extension tubing.Interview on 3/1/26, at 2:45 p.m. information was disseminated to the Director of Nursing that the facility failed to maintain a peripheral intravenous catheter site consistent with professional standards of practice for one of three residents (Resident R29).28 Pa.

Code 201.18(b)(3) Management.28 Pa.

Code 211.10(c)(d) Resident care policies.28 Pa.

Code 211.12(d)(1)(3) Nursing services.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

3/5/26, at 10:57 a.m. NHA and DON were informed that the facility failed to meet Resident R159 pain

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

Review of the facility policy Medication Storage in the facility dated [DATE], indicated medications and biologicals are stored safely, securely, and properly.

Medications requiring refrigeration or temperatures between 36F and 46F are kept in a refrigerator with a thermometer to allow temperature monitoring.

Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, and disposed of.

During an observation on [DATE], at 1:29 p.m. the Fontbonne Medication room contained the following expired supplies: -(3) 1ml 28g 1/2 safety syringe with needle expired [DATE] -(5) 28g 1/2 1 ml safety syringe needle expired [DATE] -(1) BD vacutainer push button blood collection set 0.6 x19mmx305 mm expired [DATE] During an observation on [DATE], at 1:29 p.m. the temperature of the medication fridge located in the Fontbonne Medication room was 48F.

During an interview on [DATE], at 1:30 p.m.

Licensed Practical Nurse Employee E11 confirmed that the above supplies were expired, and the medication fridge temperature was not in range as required.

Interview on [DATE], at 1:37 p.m., the Nursing Home Administrator confirmed that the facility failed to discard expired medical supplies and ensure all drugs and biologicals were stored under proper temperature controls for one of three medication rooms. 28 Pa.

Code: 211.10(c) Resident care policies. 28 Pa.

Code: 211.12(d)(2)(3) Nursing services.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005

Review of the facility policy Management of C.

Difficile Infection Procedure dated 1/1/26, indicated the facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile (C diff) infections.

Use disposable equipment whenever possible.

Thoroughly clean and disinfect with a sporicidal disinfectant (chemical disinfectants designed to destroy highly resistant bacterial and fungal spores).

Review of the admission record indicated Resident R21 admitted to the facility on [DATE], with the diagnoses of pneumonia (lung infection), Parkinson's disease (disorder of the nervous system that results in tremors), and enterocolitis due to clostridium difficile (C-diff - contagious bacteria causing severe, watery diarrhea, abdominal pain, fever, and nausea).

Review of Resident R21's physician order dated 2/12/26, indicated contact precautions for C-diff.

Please clarify with physician when isolation precautions can end.

Observation of Resident R21's room on 3/3/26, at 12:54 p.m. indicated signage of contact isolation on the closed door of the room.

Interview on 3/3/26, at 12:54 p.m.

Housekeeping Employee E4 indicated We scrub around the toilet and the sink really well.

When asked if there was anything special required to clean a room with contact isolation due to C-diff.

Interview on 3/3/26, at 12:55 p.m.

Housekeeping Employee E4 further indicated we use [NAME] Facility Plus disinfectant.

When asked if it contained bleach, housekeeper indicated they were not sure.

Review of Midlab's EPA's (Environmental Protection Agency) Reg No. 45745-11-45745 for [NAME] Facility Plus disinfectant, the product's ability to kill on hard, non-porous inanimate surfaces, did not include effectiveness against killing Cdiff.

Interview on 3/3/26, at 1:23 p.m.

Environmental Services Director confirmed the [NAME] Facility Plus disinfectant was not effective against killing C-diff according to the manufacturer's EPA Reg No. 45745-11-45745 sheet.

Interview on 3/3/26, at 2:45 p.m. interview with the Nursing Home Administrator information was disseminated to indicate the facility failed to thoroughly clean and disinfect a contact isolation room with the appropriate disinfectant for one of three residents (Resident R21). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.28 (b)(e)(1) Management. 28 Pa Code: 211.10 (d) Resident care policies.

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Concordia at Villa St Joseph 1030 State Street Baden, PA 15005