Health inspection·April 24, 2025

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on review of Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report and staff interview, it was determined that the facility failed to electronically submit direct care staffing information for one of one quarter reviewed (Fiscal Year Quarter 1 2025 - October 1, 2024, to December 31, 2024). Findings include: According to Section 6106 of the Affordable Care Act (ACA), facilities are required to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. The data, when combined with census information, can then be used to report on the level of staff in each nursing home, as well as employee turnover and tenure, which can impact the quality of care delivered. Review State Operations Manual, under section 483.70(q), revealed Mandatory submission of staffing information based on payroll data in uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Under section 483.70(q)(4), The facility must submit direct care staffing information in the uniform format specified by CMS. Under section 483.70(q)(5), The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. Review of PBJ staffing data report for Fiscal Year Quarter 1 2025 - October 1, 2024, to December 31, 2024 revealed the facility triggered for Failed to Submit Data for the Quarter. Interview with the Director of Nursing, Employee E2, revealed no other information or documentation was available for review. 28 Pa. Code 201.18(a) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395121 If continuation sheet Page 2 of 4 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 395121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Simpson House Inc 2101 Belmont Avenue Philadelphia, PA 19131 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to implement enhanced barrier precautions for four of seventeen residents reviewed (Resident R36, R50, R24, R48). Residents Affected - Some Findings Include: Review of facility policy Enhanced Barrier Precautions - Skilled Nursing reviewed July 2, 2024, revealed the facility will utilize enhanced barrier precautions to prevent the spread of multidrug resistant organisms (MDRO). Enhanced barrier precautions (EBP) expand the use of personal protective equipment (PPE) beyond situations in which exposure to blood and bodily fluids is anticipated. Enhanced barrier precautions include the use of a gown and gloves during high-contact resident care activities for residents with, but not limited to, wounds and/or indwelling medical devices regardless of infection status and MDRO colonization. Further review of facility policy revealed gloves, and gown should be available immediately outside the resident room, a waste container should be near the exit of the resident room, and EBP signage should be posted for the resident room. Review of Resident R36's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 1, 2025, revealed the resident had an indwelling catheter (also known as foley catheter - a flexible tube placed through the urethra into the bladder to help urinate and collect urine into a drainage bag). Review of Resident R50's quarterly MDS dated [DATE], revealed the resident had pressures ulcers (an open ulcer, the appearance of which will vary depending on the stage). Review of facility wound report dated April 13, 2025, confirmed Resident R50 had an arterial ulcer (open wounds caused by poor blood flow) on the right heel, and a stage III pressure ulcer (characterized by full thickness skin loss and visible fat tissue) on the sacrum. Review of Resident R36's and R50's clinical records, including physician orders and comprehensive care plans, revealed no documented evidence enhanced barrier precautions were implemented in the plan of care. Observations on April 21, 2025, at 11:00 a.m. revealed no evidence that signage was placed on Resdient R36's and R50's door to indicate that the resident's required enhanced barrier precautions. Further observations revealed no gowns or a waste container were available immediatey outside/near the exit of Resdient R36's and R50's doors. Interview and observation on April 21, 2025, at 11:02 a.m. with Resident R36 confirmed the resident still had a catheter. When questioned, Resident R36 denied that staff wear a gown when providing care. Interview on April 21, 2025, at 11:07 a.m. with Licensed Nurse, Employee E3, revealed the employee was unaware of any residents on the ground floor nursing unit that were on enhanced barrier precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395121 If continuation sheet Page 3 of 4 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 395121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Simpson House Inc 2101 Belmont Avenue Philadelphia, PA 19131 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 Level of Harm - Minimal harm or potential for actual harm Observations on April 21, 2025, at 11:24 a.m. revealed Nurse Aide, Employee E4, was in room [ROOM NUMBER] making Resident R50's bed. When questioned, Nurse Aide, Employee E4, was unaware that Resident R50 was on enhanced barrier precautions. Review of Resident R24's quarterly MDS dated [DATE], revealed the resident had an indwelling catheter. Residents Affected - Some Observation on April 21, 2025 at 10:45 a.m. revealed no signage on Resident R24's door to indicate that the resident required enhanced barrier precautions. Interview on April 21, 2025, at 10:45 a.m. with Resident R24 confirmed the resident still had a catheter and Resident R24 and family member denied that staff wear a gown when providing care. Review of Resident R48's quarterly MDS dated [DATE], revealed the resident had an indwelling catheter. Observation on April 21, 2025 at 10:55 a.m. revealed no signage on Resident R48's door to indicate that the resident required enhanced barrier precautions. Interview on April 21, 2025, at 10:57 a.m. with Resident R48 confirmed the resident still had a catheter. Further observations revealed no gowns were available immediately outside of Resident R24's and R48's doors. Interview on April 21, 2025, at 11:10 a.m. with Unit Manager, Employee E5, confirmed no enhanced barrier precaution signage was posted on Resident R24's and Resident R48's doors and no gowns were immediately available outside Resident R24's and Resident R28's doors. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395121 If continuation sheet Page 4 of 4