Health inspection·August 25, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 1, 2025, which revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift while nurse aide, Employee E4, was giving Resident R1 a shower the employee noticed the resident's heel bleeding and subsequently reported it to the licensed nurse, identified as Employee E5. Review of Resident R1's entire clinical record revealed no documented evidence that licensed nurse, Employee E5, documented a wound assessment, notified the physician of the new skin impairment or obtained treatment orders for the area. Interview on August 25, 2025, at 3:23 p.m. with Licensed Nurse, Employee E5, revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift when this employee went to Resident R1's room, the resident had asked Licensed Nurse, Employee E5, to put a bandage on the back of his/her ankle because it was bleeding. Licensed Nurse, Employee E5, subsequently applied a foam dressing to the back of Resident R1's right ankle.Further interview on August 25, 2025, at 3:23 p.m. with Licensed Nurse, Employee E5, confirmed the physician was not notified regarding the skin impairment and further confirmed a description of the wound (including measurements) was not documented in Resident R1's clinical record. Licensed Nurse, Employee E5, reported Resident R1 stated that the skin impairment was not new so the employee assumed the physician was already aware. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services. Event ID: Facility ID: 395134 If continuation sheet Page 2 of 6 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 395134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inglis House 2600 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to conduct a complete and thorough investigation related to a pressure ulcer for one of three residents reviewed (Resident R1). Findings Include:Review of facility policy Abuse, Neglect and Exploitation revised August 19, 2025, revealed the facility will thoroughly investigate all reports of suspected or alleged abuse, and neglect; as well as all injuries of unknown origin to rule out potential abuse. Documentation pertinent to the investigation shall consist of written signed statements from the resident and witnesses. Interviews should be inclusive of employees (on all shifts) having contact with the resident during the period of the alleged incident. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 27, 2025, revealed the resident was cognitively intact and had a diagnosis of paraplegia (paralysis of the legs and lower body). Continued review of Resident R1's MDS revealed the resident was at risk of developing pressure ulcers/injuries (localized damage to the skin and underlying tissue caused by prolonged pressure, shear, or friction) and was dependent (helper does all the effort) on staff for putting on/taking off footwear.Review of Resident R1's clinical record revealed a physician order dated July 6, 2024, and July 10, 2024, for skin prep to right medial ankle and right heel every day. Instructions specified to cleanse with normal saline solution, apply skin prep, and leave open to air.Review of Resident R1's wound evaluation dated June 24, 2025, revealed the resident had a Stage 3 (full thickness tissue loss in which the skin injury has gone through the skin into the fat tissue) Pressure Ulcer to the mid back inferior and Stage 4 (the most severe stage of a pressure sore, with damage to all layers of the skin, exposing muscle, tendon and bone and has a high risk of infection) Pressure Ulcer to the left ischium.Review of Resident R1's clinical record revealed a nursing note dated June 29, 2025, by Licensed Nurse, Employee E3, that indicated while this nurse was providing wound care for Resident R1's previously documented wounds (mid back and left ischium) Resident R1 made the Wound Nurse, Employee E3, aware of a new wound on his/her right ankle. Continued review of the nursing note dated June 29, 2025, revealed Licensed Nurse, Employee E3, subsequently removed Resident R1's booties to assess the area and observed a foam dressing applied to the right heel. Resident R1 reported to the Licensed Nurse, Employee E3, that he/she noticed the heel bleeding a lot during his/her shower and that his/her shoes were difficult to put on. Review of facility incident/accident investigation summary dated June 29, 2025, written up by Registered Nurse, Employee E6, revealed on June 29, 2025, while Licensed Nurse, Employee E3, was providing wound care for Resident R1, the resident stated he/she had a new wound to the right heel/ankle area. Licensed nurse, Employee E3, subsequently notified the unit manager who further assessed the new skin impairment as a stage 3 pressure wound measuring 3.5 centimeters (cm) (length) by 4.0 cm (width) by 0.3 cm (depth). Continued review of facility investigation revealed an employee statement by nurse aide, Employee E4, dated July 1, 2025, which revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift while nurse aide, Employee E4, was giving Resident R1 a shower the employee noticed the resident's heel bleeding and subsequently reported it to the licensed nurse, identified as Employee E5. Further review of employee statement by nurse aide, Employee E4, revealed Resident R1 informed nurse aide, Employee E4, that when the nurse aide from 7:00 a.m. to 3:00 p.m. shift (identified as nurse aide, Employee E7) was putting his/her shoes on a scab on the foot must have fallen off causing the skin impairment.Review of facility documentation and facility investigation revealed no documented evidence that the facility obtained a statement by licensed nurse, Employee E5 or nurse aide, Employee E7.Interview on August 25, 2025, at 12:30 p.m. with licensed nurse, Employee E3, confirmed it was Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395134 If continuation sheet Page 3 of 6 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 395134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inglis House 2600 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 0610 Level of Harm - Minimal harm or potential for actual harm Resident R1 who made this employee aware of new skin impairment to the right ankle. Licensed nurse, Employee E3, was unsure who applied the foam dressing to Resident R1's ankle and was further unsure when the area had opened. Interview on August 25, 2025, at 2:15 p.m. with Director of Nursing, Employee E2, confirmed no statement was obtained by licensed nurse, Employee E5, or nurse aide, Employee E7. 28 Pa. Code 211.12 (d)(1) Nursing services.28 Pa. Code 211.12 (d)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395134 If continuation sheet Page 4 of 6 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 395134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inglis House 2600 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide pressure ulcer treatment consistent with standards of professional practice for one of three residents reviewed (Resident R1).Findings Include:Review of facility policy Skin Integrity: Wound Monitoring revised September 22, 2016, revealed when a new wound is identified the licensed nurse will measure the wound and document findings in the electronic medical record (EMR), and notify the Registered Nurse, and Physician. The physician's order for wound care treatments should include cleansing agent, frequency, and dressings as indicated. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 27, 2025, revealed the resident was cognitively intact and had a diagnosis of paraplegia (paralysis of the legs and lower body). Continued review of Resident R1's MDS revealed the resident was at risk of developing pressure ulcers/injuries (localized damage to the skin and underlying tissue caused by prolonged pressure, shear, or friction) and was dependent (helper does all the effort) on staff for putting on/taking off footwear. Review of Resident R1's clinical record revealed a physician order dated July 6, 2024, and July 10, 2024, for skin prep to right medial ankle and right heel every day. Instructions specified to cleanse the areas with normal saline solution, apply skin prep, and leave open to air. Review of Resident R1's wound evaluation dated June 24, 2025, revealed the resident had a Stage 3 (full thickness tissue loss in which the skin injury has gone through the skin into the fat tissue) Pressure Ulcer to the mid back inferior and Stage 4 (the most severe stage of a pressure sore, with damage to all layers of the skin, exposing muscle, tendon and bone and has a high risk of infection) Pressure Ulcer to the left ischium. Review of Resident R1's clinical record revealed a nursing note dated June 29, 2025, by Licensed Nurse, Employee E3, that indicated while this nurse was providing wound care for Resident R1's previously documented wounds (mid back and left ischium) Resident R1 made the Licensed Nurse, Employee E3, aware of a new wound on his/her right ankle. Continued review of the nursing note dated June 29, 2025, revealed Licensed Nurse, Employee E3, subsequently removed Resident R1's booties to assess the area and observed a foam dressing applied to the right heel. Resident R1 reported to the Licensed Nurse, Employee E3, that he/she noticed the heel bleeding a lot during his/her shower and that his/her shoes were difficult to put on. Review of facility incident/accident investigation summary dated June 29, 2025, written up by Registered Nurse, Employee E6, revealed on June 29, 2025, while Licensed Nurse, Employee E3, was providing wound care for Resident R1, the resident stated he/she had a new wound to the right heel/ankle area. Licensed nurse, Employee E3, subsequently notified the unit manager who further assessed the new skin impairment as a stage 3 pressure wound measuring 3.5 centimeters (cm) (length) by 4.0 cm (width) by 0.3 cm (depth). Continued review of facility investigation revealed an employee statement by nurse aide, Employee E4, dated July 1, 2025, which revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift while nurse aide, Employee E4, was giving Resident R1 a shower the employee noticed the resident's heel bleeding and subsequently reported it to the licensed nurse, identified as Employee E5. Review of Resident R1's entire clinical record revealed no documented evidence that licensed nurse, Employee E5, measured the wound and documented findings of the assessment in the EMR. Further review of Resident R1's clinical record revealed no documented evidence that the Registered nurse or Physician were notified of the new skin impairment or obtained treatment orders for the area. Interview on August 25, 2025, at 3:23 p.m. with Licensed Nurse, Employee E5, revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift when this employee went to Resident R1's room, the resident had asked Licensed Nurse, Employee E5, to put a bandage on the back of Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395134 If continuation sheet Page 5 of 6 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 395134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inglis House 2600 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 0686 Level of Harm - Minimal harm or potential for actual harm his/her ankle because it was bleeding. Licensed Nurse, Employee E5, subsequently applied a foam dressing to the back of Resident R1's right ankle. Review of Resident R1's June 2025 Physician orders and Treatment Administration Record revealed no treatment orders were obtained to the resident's right ankle. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395134 If continuation sheet Page 6 of 6