Every finding on record at Concordia at Spiritrust Utz Terrace

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implement transmission-based precautions to prevent the spread of infection for one of three residents (Residents 43) on transmission-based precautions; failed to perform control measures that include daily/weekly temperature checks, water system pressure, disinfectant testing of chlorine levels in the boiler room; and failed to perform weekly water temperature checks for the entire facility from July 1, 2025, through January 19, 2026.Findings Include: Review of facility policy, titled Transmission-Based (Isolation) Precautions, revised April 2, 2024, revealed, Contact Precautions- Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Review of Resident 43's clinical record revealed diagnoses that included pseudomonas aeruginosa (a major cause of serious, potentially fatal infections in hospitalized patients, individuals with weakened immune systems) and chronic obstructive pulmonary disease (COPD- a progressive, inflammatory lung disease that restricts airflow and causes breathing difficulties). Observation of Resident 43 on May 27, 2026, at 9:39 AM, revealed Resident 43 sitting in his room. Hanging on the wall outside of Resident 43's room was a sign indicating that Resident 43 was on contact precautions and that anyone entering the room was required to put on gloves and a gown and then remove the gloves and gown before exiting the room. Further observation at that time revealed Employee 3 entering the room without applying any of the required PPE (personal protective equipment) to administer Resident 43's medications. Review of Resident 43's care plan failed to reveal a care plan regarding Resident 43's need for contact precautions. Interview with the Nursing Home Administrator (NHA) on May 28, 2026, at 1:10 PM, revealed an expectation that staff would use the correct PPE when entering residents' rooms that require it. A review of the facility policy, titled Water Management Policy, last reviewed April 1, 2026, stated the purpose is to reduce the risk for Legionnaires disease and other water pathogens associated with building water systems and devices based on the risk assessment as outlined below. Maintaining water temperatures outside the ideal range for Legionella growth (greater than 140 degrees Fahrenheit)Prevent water stagnation (flush any areas weekly such as rooms that are unoccupied) Ensure adequate disinfection (checking free and total chlorine levelsMaintain devices to prevent sediment, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella The facility water management plan included control measures to minimize the risk of hazardous conditions that can promote growth of Legionella and other waterborne pathogens. Employee 13 (Director of Buildings and Grounds) presented the log forms that should have been completed. The control measures included - free chlorine checks at the point of entry (Boiler Room) to be completed daily including hot water and cold-water temperature checks. Pressure checks of the water system daily. Additionally, four randomly chosen resident rooms are to have hot and cold-water temperature checks weekly. Per the facility water management plan, if any control measures are out of limits the Supervisor or Director of Buildings and Grounds will be notified immediately During an interview with the Employee 13 (Director of Buildings and Grounds), the Employee stated that the facility was unable to provide any documented control measures from July 1, 2025, through January 19, 2026, and added that control measures were not performed because of newly hired employees and a failure to assign the task to any staff from July 1, 2025, through January 19, 2026. During an interview with the NHA on May 28, 2026, at 10:08 AM, the NHA agreed that the waterborne pathogen control measures should have been assigned and completed based on the facility water management plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)Management

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food safety in the kitchen; failed to store clean dishes in a sanitary manner in one of one service kitchen; failed to provide a sanitary condition in the main kitchen, one of one nourishment room refrigerator, and one of one dining room refrigerators; and failed to serve food in a sanitary manner during one of one tray service line observations. Findings include: Review of facility policy, titled Date Marking for Food Safety Procedure, with a last revised date of September 11, 2025, and a last review date of April 1, 2026, revealed, in part, 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of the day/date of opening, and the day/date the item must be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.) 6. A Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. Review of facility policy, titled Food Safety Requirements, with a last revised date of April 3, 2024, and a last review date of April 1, 2026, revealed, in part, Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. e. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food. f. Employee hygienic practices. Practices to maintain safe refrigerated storage include: Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination c. Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall wash hands according to facility procedures. b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. Tour of the main kitchen on May 26, 2026, between 9:43 AM and 10:00 AM, with Employee 9 (Cook) revealed the following observations:1) In the walk-in refrigerator there was an open bag of vanilla yogurt with no opened date indicated and a metal tray of biscuits dated May 23, 2026, with two tears noted in the foil covering the tray.2) In the walk-in freezer there was a plastic bag of an unlabeled food item with no date indicated that had a tear in the plastic approximately four inches in length. Employee 9 identified the item as a soup.3) On a metal rack containing spices and seasoning there was an opened container of nutmeg dated July 25, 2025; an opened container of curry dated October 28, 2025; an opened container of ginger dated October 28, 2025; an opened container of ginger with no open date indicated but delivery label indicated that it was delivered on January 10, 2025; an opened container of coriander dated October 28, 2025; an opened container of sweet and smoky rotisserie seasoning dated September 5, 2025; an opened container of browning and seasoning sauce dated March 14, 2023, with a manufacturer best by date of July 14, 2024; and an opened bottle of fine [NAME] cooking wine dated September 19, 2025, with a manufacturer best by date of April 17, 2026. Employee 9 indicated that the spices are dated for the date they are received at the facility and that she thought spices were to be discarded after six months but would need to verify that with the dietary manager.4) The lid on the flour bin was slid to the side, creating an opening in the container, and the scoop was noted to be stored down inside the flour in the bin. Employee 9 reached in with her bare hands and removed the scoop from inside the flour.5) The test strips for the three-compartment sanitation sink expired on December 1, 2025.6) On a shelf in a food prep area was an opened bottle of vanilla flavoring dated May 30, 2025. Observation on the service kitchen on May 26, 2026, at 10:04 AM, with Employee 10 (Dietary Aide) revealed an uncovered serving rack of plates stored upright sitting directly under a window with an air conditioning unit present and running. Employee 10 indicated that this kitchen area had gotten so hot and that maintenance had just recently placed the unit there to help. Employee 10 said that staff do turn the unit off when serving food because it blows directly onto the food. Observation of a refrigerator located in the dining room by the beverage dispenser on May 26, 2026, at 10:10 AM, revealed a black colored splatter in the back of the refrigerator and a black colored spill in the bottom of the refrigerator. During an immediate staff interview with Employee 14 (Dietary Aide), she said that dietary staff wipe it down when they have time. Observation of the nourishment area near the main nursing desk on May 26, 2026, at 10:17 AM, revealed individual packets of jellies, salad dressings, and hot chocolate packets that had no dates noted on the packaging. In addition, the refrigerator was noted to have small brown colored spills on a shelf and in the bottom. During a staff interview with Employee 5 (Dietary Manager) on May 27, 2026, at 10:32 AM, he confirmed that the spices and seasoning should be discarded after six months and indicated that they were a little behind. In addition, Employee 5 acknowledged that he was aware that the air conditioning unit in the service kitchen was blowing over dishes and that he had reported this concern. During a tray line observation in the service kitchen on May 27, 2026, at 11:50 AM, Employee 10 was observed using her gloved hands to pick up the paper tray tickets, then touch the eating surface of plates twice, push spaghetti noodles back onto plate twice, and pick up garlic roll once. During an immediate staff interview with Employee 10 and Employee 5, both acknowledged the observations and confirmed that sanitary conditions were not followed. During a final staff interview with the Nursing Home Administrator on May 27, 2026, at 1:04 PM, he confirmed that he would expect food to be stored, prepared, and served in sanitary manner as well as appropriate sanitation of equipment. 28 Pa. Code 201.14 Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.6(f) Dietary services.

Based on observations, review of facility provided documentation, and staff interviews, it was determined that the facility failed to ensure the resident environment is free from accident hazards in the activity room.Findings include: Observation of the Activity Room on May 26, 2026, at 10:15 AM, revealed the presence of a stove. Upon the surveyor turning one of the burners to the on position, the burner was noted to begin heating. Employee 11 (Activity Director), who was noted to be in her office in the corner of the same Activity Room with the door and window blinds closed, was notified immediately of the observation. Employee 11 accompanied the surveyor to the stove and acknowledged that the stove burners and oven could be turned on. Employee 11 indicated that the main power to the stove was controlled by a key lock box located in her office. There was a key noted in the lock box and it was turned to the on position. Employee 11 immediately turned the key to the off position, and recheck of the stove revealed that it could not be turned on. When asked when the stove had last been utilized, Employee 11 indicated that she would have to investigate and follow-up with surveyor. There were no residents noted in the area at the time of the observation. Review of the facility May Activity Calendar revealed a cooking activity on May 13, 2026, at 2:00 PM. During a staff interview with the Nursing Home Administrator (NHA) on May 27, 2026, at 10:30 AM, he confirmed that the last cooking activity was on May 13, 2026, as per the Activity Calendar. He further indicated that he had removed the key from the lock box in the Activity Director's office and was in the process of writing a policy to address the safe use of the stove. During a final staff interview with the NHA on May 27, 2026, at 1:06 PM, he confirmed that he would have expected the power to the stove to be turned off when staff are not present, but that he believed that there would not be a resident in that area unattended. 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.

Based on observation, clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure each resident the right to a dignified existence and be treated in a manner and environment that enhances his or her quality of life for one of five residents observed for the use of a foley catheter (Resident 4). Findings Include: Review of the facility's policy, titled Catheter Care, Urinary, dated July 2015, read, in part, Be sure the catheter tubing and drainage bag are kept off the floor and in a dignity bag. Review of Resident 4's physician's orders revealed diagnoses that included chronic kidney disease (gradual loss of kidney function impairing their ability to filter waste) and bladder neck obstruction (a blockage in the neck at the very bottom of the bladder). Review of Resident 4's interdisciplinary plan of care revealed the need for the use of a suprapubic catheter (a thin, hollow tube made of rubber, silicone, or plastic that allows urine to bypass the urethra and drain directly from the bladder through an incision in the lower abdomen, typically a few inches below the navel). An observation on May 26, 2026, at 10:44 AM, revealed Resident 4 ambulating with his rolling walker, in the hallway with his catheter bag and tubing exposed. Both the bag and the tubing contained visible urine. An interview with the Nursing Home Administrator on May 27, 2026, at 10:11 AM, revealed that Resident 4's catheter bag should have been covered with a dignity bag. 28 Pa. Code 211.12 (b) (1) (2) (5) Nursing services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the main kitchen walk-in freezer and in the kitchenette food temperature log. Findings include: Review of facility policy, Labeling and Dating, revised May 14, 2018, read, in part, all food items must be labeled with either a manufacturer label or handwritten label. Upon receipt all food items, must be dated with receiving date. Review of facility policy, Food Service Temperature Logs, last reviewed March 2010, read, in part, food temperatures must be recorded on all hot and cold foods prior to meal service using the Temperature and Meal Evaluation Form. Observation in the walk-in freezer in the main kitchen on April 28, 2025, at 9:32 AM, revealed there were three packages of naan bread out of the cardboard case and not date marked. During an interview with the Employee 4 (General Manager) on April 28, 2025, at 9:32 AM, it was revealed that the packages should've been date marked with a received date or left in the case which should be date marked. Observed of food temperature logs in the Kitchenette on April 28, 2025, at 9:44 AM, revealed eight dinner meals over the past 27 days that the food temperatures weren't recorded. During an interview with Employee 4 on April 28, 2025, at 9:44 AM, it was revealed that the temperature log should be completed for all meals. During an interview with the Nursing Home Administrator on April 29, 2025, at 2:00 PM, it was revealed that all items should be labeled with a received date, and that food temperatures should be recorded for each meal. 28 Pa code 211.6 - Dietary Services

Based on resident interviews, observation, completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed (April 29, 2025, lunch meal). Findings include: During an interview with Resident 1 on April 28, 2025, at 11:00 AM it was revealed that she doesn't like the taste of the food, and the hot food is often cold. Resident 1 stated that she usually eats in her room for breakfast and lunch and will go to the dining room for dinner. Review of Resident 1's daughter's grievance/concern submitted to the facility on [DATE], read, in part, that her mother doesn't receive the menu items she selects because the facility runs out of food, and the food she gets is frequently inedible. During an interview with Resident 33 during the initial pool process on April 28, 2025, it was revealed he doesn't like the taste of the food, and the hot food it is often cold. Review of facility form, Tray Line Test Tray Audit, revised January 2020, read, in part, test tray standard for hot entree and vegetable is greater than or equal to 135 degrees Fahrenheit. Test tray is also evaluated for adequate flavor and texture of the food. A test tray completed on April 29, 2025, at 1:17 PM revealed adequate portions size, the vegetable alfredo wasn't palatable for taste it was bland, the texture of the broccoli was over cooked/very soft, and the vegetable alfredo and broccoli weren't palatable for temperature. The test tray was placed on a meal cart to be delivered with room trays; 18 minutes had elapsed between the time the test tray was prepared from the service line and presented for evaluation. Employee 3, [NAME] President of Operations for the consultant Food Service Company, took temperatures of the food items at the time the test tray was served for evaluation. The following were the recorded highest temperatures: Vegetable alfredo- 133 degrees Fahrenheit Baked sweet potato- 143 degrees Fahrenheit Broccoli- 139 degrees Fahrenheit Butterscotch pudding - room temp Iced tea- 46 degrees Fahrenheit Coffee- 137 degrees Fahrenheit During an interview with Employee 3, [NAME] [NAME] President of Operations for the consultant Food Service Company, on April 29, 2025, at 1:20 PM it was revealed that the temperature of the vegetarian alfredo and the broccoli weren't to company standards. It was acknowledged that it took a while to assemble the room trays and therefore the tray sat longer than expected. During an interview with the Nursing Home Administrator on April 29, 2025, at 2:00 PM it was revealed that foods should be served at adequate temperatures and should be palatable. 28 Pa. Code 201.14. Responsibility of licensee 28 Pa code 211.6 - Dietary Services

Based on review of select food service committee meeting minutes, resident and staff interviews, and observations, it was determined that the facility failed to produce sufficient food to support resident requests based on the posted menu for one meal observed. Findings include: Review of Skilled Care Food Committee Meeting minutes dated April 8th, 2025, residents revealed that food items run out and they don't get what is on the menu. During an interview with Resident 1 on April 28, 2025, 11:00 AM, the Resident revealed that she doesn't like the taste of the food and that she would complete a selection menu, but she does not always get what she selected because they ran out of food. Review of Resident 1's daughter's grievance/concern submitted to the facility on [DATE], read, in part, that her mother doesn't receive the menu items she selects because the facility runs out of food, and the food she gets is frequently inedible. Observation of the posted menu outside of the dining room on April 29, 2025, at 12:00 PM, revealed the lunch menu was citrus roasted pork, baked sweet potato, broccoli, and butterscotch pudding, and the alternate entree was vegetable Alfredo. Additional observation on April 29, 2025, at 1:06 PM, revealed Employee 2 altered the resident menu selections on Residents' 14, 22, 24, 187, and 188's meal tickets. Employee 2 confirmed that they ran out of sweet potato, which was the starch on the posted menu and, therefore, they substituted mashed potatoes. During an interview with Employee 3 on April 29, 2025, at 1:20 PM, it was revealed that production sheets aren't utilized. It was also revealed that residents choose their menu selection at time of service. During an interview with the Nursing Home Administrator on April 29, 2025, at 2:00 PM, it was revealed that sufficient food should be prepared to serve the posted menu. Pa code 211.6 - Dietary Services

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 12 residents reviewed (Residents 14 and 26). Findings Include: Review of Resident 14's clinical record revealed diagnoses that included atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart [atria] beat irregularly and often too rapidly) and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood effectively). Review of Resident 14's physician orders revealed an order for Xarelto (anticoagulant medication) 15 mg in the morning for atrial fibrillation, with a start date of February 9, 2023. Review of Resident 14's care plan failed to reveal a care plan with a focus area related to anticoagulant medication. Interview with the Director of Nursing (DON) on April 29, 2025, at 10:55 AM, revealed they thought an adequate care plan had been enacted into Resident 14's care plan. Review of Resident 26's clinical record revealed diagnoses that included stage 3 pressure ulcer of the sacrum (a deep wound that extends through the skin into the fatty tissue below, but does not expose muscle or bone, located on the sacrum) and stage 3 pressure ulcer of the back (a stage 3 pressure ulcer located on the back). Review of a wound evaluation dated March 5, 2025, revealed the discovery of a stage 3 pressure wound on Resident 26's sacrum. Review of a wound evaluation dated April 9, 2025, revealed the discovery of a stage 3 pressure wound on Resident 26's left upper back, the evaluation also revealed that the stage 3 pressure wound on the sacrum was still present. Review of the most recently completed wound evaluation dated April 23, 2025, revealed that both stage 3 pressure wound on Resident 26's back and sacrum were still present. Observation of a dressing change on April 29, 2025, at 9:45 AM, revealed that Resident 26 still had stage 3 pressure wounds on their back and sacrum. Review of Resident 26's care plan failed to reveal a care plan with a focus area related to pressure wounds or skin care. Interview with the DON on April 30, 2025, at 10:30 AM, revealed that the care plan for Resident 26's ongoing skin care had been inadvertently removed. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review observations, and staff interviews, it was determined that the facility failed to provide respiratory services for two of fifteen residents reviewed (Resident 10 and 28). Findings include: Review of facility provided policy titled, Oxygen Administration, reviewed March 2024, revealed that the humidifier bottle should be labeled with the date and time changed. Observation of Resident 10 on May 13, 2024, at 10:06 AM, revealed the resident sitting in their bed. On the side of the bed was an oxygen concentrator and the oxygen concentrator humidification bottle was labeled that it was put into use on May 3, 2024. Review of Resident 10's clinical record revealed diagnoses that include diabetes mellitus (a group of diseases that result in too much sugar in the blood (high blood glucose)) and respiratory failure (when the lungs can't release enough oxygen into your blood). Review of Resident 10's physician's orders on May 16, 2024, revealed an order to change oxygen equipment and clean the oxygen concentrator filter every week. Review of Resident 10's Medication Administration Record for the month of May 2024, revealed that this should have been completed on May 9, 2024. Observation of Resident 28 on May 13, 2024, at 10:34 AM, revealed the resident sitting in a lounge chair beside their bed. Beside the chair was an oxygen concentrator and the oxygen concentrator humidification bottle labeled that it was put into use on May 3, 2024. Review of Resident 28's clinical record revealed diagnoses that include atrial fibrillation (a type of heart arrhythmia that causes the upper chambers of the heart to beat irregularly and quickly) and congestive heart failure (is a complex clinical syndrome characterized by inefficient myocardial performance, resulting in compromised blood supply to the body). Review of Resident 28's physician's orders on May 14, 2024, revealed an order to change and date oxygen equipment (tubing and humidifier bottle) and clean the oxygen concentrator filter every week. Review of Resident 28's Medication Administration Record for the month of May 2024, revealed that this should have been completed on May 9, 2024. During an interview with the Director of Nursing on May 16, 2024, at 10:35 AM, revealed that Resident 10 and 28 required supplemental oxygen and their humidification bottles should have been changed weekly as ordered by the physician. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, clinical record review and staff interview it was determined that the facility failed to ensure a resident unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for one of fifteen residents reviewed (Resident 12). Findings Include: Activities of Daily Living (ADL's- a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, other personal hygiene and mobility). Review of Resident 12's clinical record revealed diagnoses that included hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and cerebral vascular accident (a stroke, also referred to as a cerebral vascular accident (CVA) or a brain attack, is an interruption in the flow of blood to cells in the brain). An observation and interview with Resident 12, on May 14, 2024, at 9:11 AM revealed the resident in the room and found to have significant facial hair. The facial hair was most prominently observed on the upper lip and chin areas. The interview with Resident 12 revealed feeling depressed regarding the amount of facial hair and stated she would accept staff assistance with removing the hair from her face. Review of Resident 12's interdisciplinary plan of care revealed impaired function with activities of daily living due to medical diagnoses. However, no documentation regarding Resident 12's refusal of personal hygiene care, including shaving. An interview with the Director of Nursing (DON), on May 14, 2024, at 10:01 AM revealed Resident 12 is believed to have a condition that promotes excessive hair growth. The interview also revealed Resident 12 is documented to have last been shaved by staff on April 28, 2024. An additional interview with the DON, on May 15, 2024, at 2:50 PM revealed Resident 12 was reapproached, and staff assisted the resident with shaving her facial hair. A final interview with the DON, on May 16, 2024, at approximately 11:30 AM revealed the facility had no additional information to provide regarding the prominent amount of facial hair found during the interview with Resident 12 on May 14, 2024. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on document review and staff interview, it was determined that the facility failed to ensure the quality assessment and assurance committee consists of the minimum required members for three of three quarterly meeting sign-in documents reviewed (October 2022, January 2023, and April 2023). Findings Include: Review of the facility's attendance record for the months of October 2022, January 2023, and April 2023 revealed no record of participation by the facility's Infection Preventionist. An interview with the Nursing Home Administrator on May 23, 2023, at 12:58 PM, revealed the facility had no qualified Infection Preventionist on staff at that time and during those meetings. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on interviews, employee training documents, and regulations, it was determined that the facility failed to have an Infection Preventionist (IP) that completed the approved program for specialized training in infection prevention and control to obtain final certificate with 19.3 CEU (continuing education units). Findings include: The Centers for Medicare and Medicaid Services regulation S483.80(b)(4) states, The facility must designate one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's IPCP (Infection Prevention Control Program) that have completed specialized training in infection prevention and control. Completion of the Centers for Disease and Control (CDC) Train Program requires passing the examination and then eligibility to obtain the official certificate of completion with 19.3 CEUs being completed. Additionally, the individual must work a minimum of part-time within the facility. Employee 6 (Registered Nurse) assumed the role as IP at the facility on January 1, 2023. The previous IP resigned from the facility on September 9, 2022. During an interview with the Director of Nursing (DON) on May 22, 2023, at 1:50 PM, Employee 6's IP certificate of completion by CDC Train credentials were requested that showed the 19.3 CEUs were completed. The DON stated Employee 6 had a deadline of 30 days to repeat the test and complete the post-test evaluation, and that deadline was not met by Employee 6. During an interview with the Nursing Home Administrator (NHA) on April 13, 2023, NHA stated the current IP is unable to provide a certificate of completion of the program for specialized training in infection prevention and control as specified in the manual. The facility was also unable to provide proof that the program is supported by CDC or CMS as an approved program for IPs. 28 Pa. Code 201.18(b)(2) Management

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 13 residents reviewed (Resident 37). Findings Include: Review of Resident 37's clinical record revealed diagnosis that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 37's MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated April 20, 2023, revealed that Section O0100 Special Treatments, Procedures, and Programs, part K. Hospice care, was marked No, indicating that Resident 37 had not received Hospice services during the 14 day look back period. Review of physician's orders in Resident 37's electronic medical record revealed a physician's order from April 12, 2023, revealed that Resident 37 was discharged from Hospice services as of April 12, 2023. Interview with the Director of Nursing on May 24, 2023, at 10:00 AM, revealed that she agreed that Resident 37's status of receiving Hospice services should have been reflected on the MDS dated [DATE]. 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure the attending physician or prescriber responded to medication regimen reviews, completed by a consultant pharmacist, in a timely manner for two of 13 residents reviewed (Residents 6 and 26). Findings include: Review of facility policy, titled Drug Regimen Review Monthly Admission/Readmission, revised February 2023, revealed in step 4. that when the Consultant Pharmacist's medication regimen review is completed, it is provided to the attending physician/prescriber- the physician must review and act or respond within 30 days. Review of Resident 6's clinical record revealed diagnoses that included chronic osteomyelitis (a bone infection that doesn't go away with treatments) and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). Review of Medication Regiment Review form for Resident 6 dated December 12, 2022, revealed that a review was completed by the consultant pharmacist and recommendations were made. Further review revealed that no physician or prescriber responded to the report until February 23, 2023; 73 days later. Review of Resident 26's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder) and diabetes (a metabolic disease, involving inappropriately elevated blood glucose levels). Review of Medication Regiment Review form for Resident 26 dated December 12, 2022, revealed that a review was completed by the consultant pharmacist and recommendations were made. Further review revealed that no physician or prescriber responded to the report until February 23, 2023; 73 days later. Interview with the Director of Nursing on May 24, 2023, at 1:30 PM, revealed that the physician did not respond to Resident 6's and 26's medication regiment reviews in a timely manner because there was a problem with the process, which they are working on fixing. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(c) Resident care policies

Based on interviews and record review, the facility failed to ensure that the care plan interventions were followed to have staff remain with the resident when toileting for one of three Resident's reviewed (Resident 1). Findings include: A review of the clinical record for Resident 1 on February 15, 2022, revealed diagnoses that included cerebral vascular accident (CVA) with left sided hemiparesis and hemiplegia (stroke caused by disrupted blood flow to the brain, resulting in residual effects of left sided weakness) and memory deficit following cerebral infarction. A care plan dated February 2023, indicates the Resident is at risk for falls due to history of CVA, left sided weakness, and balance problems. Intervention includes, but not limited to, call bell within reach; non-skid socks; and staff member must stay with Resident while on toilet. The intervention to remain with the Resident while on the toilet was initiated May 24, 2021, and revised to state the same on January 29, 2023. A review of the clinical record revealed that on January 27, 2023, at 4:20 PM, Resident 1 was on the toilet and rang the bell for assistance. During an interview with the Nursing Home Administrator (NHA) on February 15, 2023, the NHA stated that he responded to Resident 1's call bell on February 15, 2023, and he recalled it being close to 4:30 PM, when he knocked on the door Resident 1 stated, don't come in I'm on the commode. The NHA stated that he informed Resident 1 that he would leave the call bell on and inform the staff who were assisting another Resident with the Hoyer lift at that time. On January 27, 2023, at 4:30 PM, Resident 1 attempted to transfer herself from the bedside commode and was found in her room, lying on her right side. Resident 1 informed the staff that she was tired of waiting and decided to transfer herself. During an interview with the Director of Nursing (DON) on February 15, 2023, at approximately 12:00 PM, the DON stated that she and Employee 1 (Nursing Supervisor) had initially transferred Resident 1 to the bedside commode and after she provided assistance, she left the room. The DON interviewed Employee 1 after the fall, who admitted he was also called away from the room, leaving Resident 1 alone on the bedside commode. The DON reviewed the care plan herself, and reviewed the care plan with Employee 1 at that time. No injuries were sustained. During an interview with the NHA and DON on February 15, 2023, at approximately 1:00 PM, they both agreed the care plan interventions should have been followed, and staff should remain with the Resident when on the commode. 28 Pa. Code 211.11(d)Resident care plan

Based on observation, document review, and staff interview, it was determined that the facility failed to ensure food is prepared and distributed in accordance with professional standards for food service safety for one of two kitchen areas reviewed (facility kitchenette). Findings Include: Review of the facility's policy, titled Use of Hair Restraints recently revised September 2021, reads Dining service staff must wear hair restraints as a preventative measure against the spread of illness and to prevent hair from contacting exposed food. Observations in the facility's kitchenette area on June 6, 2022, at 6:41 PM, revealed Dining Service Aides 1 and 2 performing duties without the use of hair restraints. An inteview with the Dining Services General Manager on June 9, 2022, at 9:44 AM, confirmed staff should wear hair restraints while in the facility's kitchenette area. 28 Pa. Code 211.6 (f) Dietary services

Based on review clinical records, observations, facility policy review, and staff interviews, it was determined that the facility failed to provide respiratory services for one of fourteen residents reviewed (Resident 26). Findings include: Review of facility provided policy titled, Oxygen Administration, dated 2006, revealed, Check physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 26's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on June 6, 2022, at 6:45 PM, Resident 26 was lying in their bed. Observation of Resident 26 revealed that Resident 26 was receiving supplemental oxygen, via nasal canula, at 3 liters per minute. Review of Resident 26's physician orders, on June 7, 2022, failed to reveal any physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the Nursing Home Administrator on June 9, 2022, at 11:15 AM, it was revealed that the expectation is that nurses follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of fourteen residents reviewed (Resident 26). Findings include: Review of Resident 26's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 26's current Care Plan on June 7, 2022, revealed a care plan with the focus of: I have an infection of the (specify): [CONDITION(S)] (urinary tract infection), Initiated April 28, 2022, with no revisions. Review of Resident 26's MAR (Medication Administration Record) for the month of April 2022, revealed that Resident 26 received [MEDICATION(S)] 500 mg twice daily for two days to treat an [CONDITION(S)]. Interview with the Nursing Home Administrator on June 9, 2022, at 11:30 AM, revealed that Resident 26's care plan should have been updated to reflect that the [CONDITION(S)] was resolved in April 2022. 42 CFR 483.21(b) Comprehensive Care Plans. 28 Pa. Code 211.11(d)(e) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of fourteen residents reviewed (Resident 15). Findings include: Review of facility policy, Tube Feeding Standard, last revised April 1, 2016, revealed Feeding solution is hung per manufacturer recommendations. Irrigation syringes are labeled with resident name, date, and changed daily on 11-7 shift. Review of package insert for [MEDICATION(S)] 1.2 cal dated June 29, 2021, revealed, once opened use within 48 hours. Review of Resident 15's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 15's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 15 on June 6, 2022, at 6:34 PM, revealed that the Resident was receiving [MEDICATION(S)] 1.2 cal at 80 ml per hour. Further observation revealed that the bottle of [MEDICATION(S)], tubing, and water flush bag were not labeled with a time or date that they were opened and hung at the Resident's bedside. Interview with Nursing Home Administrator on June 9, 2022, at 11:30 PM, revealed that the [MEDICATION(S)] should have been labeled with the date that it was opened, and the [MEDICATION(S)] should have been being provided from 8:00 PM until 4:00 PM as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on document review and staff interview, it was determined that the facility failed to inform each resident, in writing, of services available in the facility and charges for those services, including any charges for services not covered under Medicare A, for two of three residents reviewed (Residents 37 and 138). Findings Include: Review of the Skilled Nursing Facility Beneficiary Protection Notification Review form, completed on behalf of Resident 37, revealed a last covered day of Medicare A services as May 31, 2022. Review of the facility's documentation revealed the facility had no information to confirm Resident 37 received the Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form detailing the non-covered facility charges and services that may be the responsibility of Resident 37. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review form, completed on behalf of Resident 138, revealed a last covered ay of Medicare A services as January 26, 2022. Review of the facility documentation revealed the facility had not reviewed or completed the required SNF-ABN, with Resident 138 or the Resident's responsible party. An interview with the Nursing Home Administrator, on June 9, 2022, at 9:08 AM, revealed the facility's billing staff provided the information for review. No additional information was provided by the facility at the conclusion of the full health survey regarding the SNF-ABN forms for Residents 37 and 138. 28 Pa. Code 201.14 Responsibility of licensee 28 Pa. Code 211.5 (f) Clinical records

Based on review of clinical records, facility reports and dietary meal tickets, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that residents were not served foods they were allergic to, for one of 12 residents reviewed (Resident 25), which caused harm with an allergic reaction; requiring a dose of po (oral) [MEDICATION NAME], a dose of IM (intramuscular) [MEDICATION NAME] and the administration of an inhaler containing ProAir HFA aerosol solution. Findings include: Review of Resident 25's (MONTH) 2019 physician orders [REDACTED]. (cancer that originates in your lymphatic system, the disease-fighting network spread throughout your body). Review of Resident 25's admission record revealed allergies [REDACTED]. Review of Resident 25's interdisciplinary plan of care reads, in part, I have a nutrition problem or potential risks of multiple food allergies [REDACTED].>Review of a report submitted by the facility, dated (MONTH) 2, 2019, at 9:25 a.m. revealed Resident 25 was served breakfast in her room. The meal included a muffin, which contained bananas, which the resident has a sensitivity to. That sensitivity is marked on her meal ticket, is noted in her clinical record and is known by dining staff. The nursing staff member serving the meal to the resident was told that the muffin was a blueberry one when she was given the tray. The resident took approximately one and one-half bites of the muffin, believing that it was a blueberry muffin, and began to feel a tightness in her throat and chest area. The charge nurse was immediately notified and provided a dose of po (oral) [MEDICATION NAME] and an IM (intramuscular) dose of [MEDICATION NAME]. Resident was also given an inhaler containing ProAir HFA aerosol solution with effect. Review of the facility's incident report dated (MONTH) 2, 2019, reads Resident had an allergic reaction after ingesting a muffin made with bananas and chocolate. Stated that she felt congesting building in her chest followed by 'burning' in her chest. Review of Resident 25's meal ticket dated (MONTH) 2, 2019, reads, in part allergies [REDACTED]. Review of the facility's Team Member Witness Statement form, most recently revised on (MONTH) 1, (YEAR), completed by Nursing Assistant 1 (NA1) dated (MONTH) 2, 2019, reads, in part On 1/2/19, there were no printed meal tickets, so I asked dietary what was on the menu .I ordered coffee and a blueberry muffin for (Resident 25). I was never informed there was banana baked inside of the blueberry muffin. I then gave it to (Resident 25) not knowing. She said she only took about one bite when she knew and started having an reaction to it. Review of the witness statement by Dining Services Aide 1 (DSA 1) dated (MONTH) 2, 2019, reads, in part The nurse gave me the ticket for (Resident 25) for breakfast and it said coffee and muffin. So I gave the nurse the coffee and muffin. But I didn't know that (Resident 25) was allergic to bananas until I look at the diet sheet. The nurse ask me if there was bananas in the muffin after (Resident 25) had the allergic reaction. I told her that there was bananas in the muffin. Review of Resident 25's annual Minimum Data Set assessment (MDS-a tool used to assess all care areas specific to the resident), dated (MONTH) 4, (YEAR), revealed under Section C-Cognitive Patterns a Brief Interview for Mental Status score of 15/15. This score denotes intact cognition. An interview with Resident 25 on (MONTH) 14, 2019, at 10:07 a.m. revealed she was served bananas although she has an allergy. Resident 25 expressed concerns and fear, following the incident. An interview with the Nursing Home Administrator (NHA) on (MONTH) 17, 2019, at 9:15 a.m. revealed Resident 25 was given the banana muffin with chocolate chips. The staff thought the blueberries were chocolate chips. DS 1 gave the muffin to NA 1 and told her (NA) 1 it was blueberry. An interview with the Dining Services General Manager 1, on (MONTH) 17, 2019, at 10:01 a.m. revealed DSA 1 misunderstood what the muffin consisted off and failed to check the diet sheet for food allergies [REDACTED]. An additional interview with the NHA, on (MONTH) 17, 2019, at 12:47 p.m. revealed an expectation that staff would show more awareness for residents with food allergies [REDACTED]. The facility failed to provide the correct dietary food as per the diet of Resident 25 which resulted in harm when Resident 25 ingested part of a banana muffin, experienced having a tightness in her throat and chest area and was administered a dose of po (oral) [MEDICATION NAME], IM (intramuscular) dose of [MEDICATION NAME] and given inhaler containing ProAir HFA aerosol solution. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 2/22/18, 1/26/17. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/26/17. 28 Pa. Code 211.12(d)(3) Nursing services.