Inspection·July 17, 2023

F 0809 28 Pa. Code: 201.14(a) Responsibility of license Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395278 If continuation sheet Page 2 of 5 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 395278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Villa 110 West Wissahickon Ave Flourtown, PA 19031 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review and staff interview, it was determined that the facility failed to ensure complete documentation related to blood sugar levels for one of 24 records reviewed. (Resident R33) Findings include: Review of Resident R33's Minimum Data Set (MDS- assessment of resident care needs) significant change assessment dated [DATE] indicated that the resident had an active diagnosis of diabetes mellitus (a disorder of carbohydrate metabolism, whereby, the body has an impaired ability to produce or respond to insulin and maintain proper blood glucose in the blood). Continued review of the MDS assessment revealed that this resident was using insulin injections regularly. Review of Resident R33's July 2023 physician's order indicated an order for Novolog (insulin) 5 units to be administered to Resident R33 at breakfast for a blood glucose reading of greater that 351. The physician's order for Resident R33 indicated that Novolog (insulin) 7 units was to be administered at mid-day and evening. Review of Resident R33's July 2023 Medication Administration Record revealed that on July 2, 2023 the blood glucose reading was 467, July 5, 2023 the blood glucose reading was 451 and July 8, 2023, blood glucose was 459. Clinical record review revealed that the physician had ordered the nursing staff to recheck to blood glucose after two hours; if the level obtained was greater than 400; which was indicative of hyperglycemia. Clinical record review for Resident R33 revealed that the nursing staff failed to document the rechecking of the blood glucose after two hours on July 2, 5 and 8, 2023. Interview with the Director of Nursing, Employee E2, and Licensed nurse, Employee E3 on July 13, 2023 at 2:00 p.m. confirmed that there was no documentation that the resident's blood sugar was recheck after 2 hours. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211,12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395278 If continuation sheet Page 3 of 5 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 395278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Villa 110 West Wissahickon Ave Flourtown, PA 19031 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, clinical record review, observation, and interview with staff, it was determined that the facility failed to maintain proper infection control practices related to hand hygiene and wound care for one of 24 residents reviewed (Resident R39). Residents Affected - Few Findings include: Review of facility policy titled Wound Care Policy and Procedure, dated May 2023, revealed that wound care is to be done following aseptic technique. Review of the Pennsylvania Department of Health document titled Wound Care Observation Checklist for Infection Control, dated April 2018, revelaed that gloves should be changed and hand hygiene performed when moving from dirty to clean wound care activities. Review of clinical documentation for Resident R39 revealed that she had an unstageable, facility acquired pressure ulcer on her right calf (an injury formed by pressure on the skin, classified into stages based on the depth of the wound and the layers of skin, fat and muscle involved; wounds are unstageable when they contain too much dead tissue to visualize the base of the wound) first identified on April 10, 2023. Other wounds present from admission included a stage 4 pressure ulcer (a wound that is completely through the skin and involving the underlying fat and muscle tissue) on her sacrum, unstageable pressure wounds to both of her heels, a deep tissue injury (a pressure related wound with intact skin) of the side of her left great toe, and a non-pressure related wound of her right second toe. Continued review revealed that Resident R39 was admitted on [DATE], and had diagnoses including, but not limited to, stage 4 pressure ulcer of sacral region, unspecified protein-calorie malnutrition, peripheral vascular disease, unspecified, and muscle weakness. Observation of wound care for Resident R39 was conducted on July 14, 2023, at 9:55 a.m. with Employee E14, the wound care Registered Nurse for the facility. Employee E14 prepared a clean field and assembled the wound care supplies for Resident R39. Supplies assembled included two open packages containing partial sheets of DermaGinate/Ag dressing (a highly absorbent dressing which is used for wounds with secretions, which is also infused with silver as an antimicrobial agent), normal saline solution, rolled gauze, skin prep pads (premedicated towelettes which are applied to create a barrier against moisture, adhesive or friction), two foam dressings with adhesive borders which had been labeled with the current date, several 2x2s (two cm long by two cm wide gauze pads), several 4x4s (four cm long by four cm wide gauze pads), cotton tipped applicators, and Santyl ointment (an ointment which is used to help breakdown dead tissue in a wound to allow the wound to heal). Interview with Employee E14 at this time of the observation revealed that the DermaGinate/Ag dressings had been opened and partially used during previous wound care, and that the remaining product had been saved for future use. She also stated that sacral wound treatment was performed by the prior shift. Employee E14 performed hand hygiene and put on clean gloves. She removed the soiled dressing from Resident R39's right calf, then she performed hand hygiene and put on clean gloves. She used a 4x4 soaked with saline to cleanse the wound. At this time, she did not perform hand hygiene and put on clean gloves. She used a cotton applicator to apply Santyl to the wound bed, applied a 2x2 soaked with saline, applied skin prep to the area around the wound, and covered it with a foam dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395278 If continuation sheet Page 4 of 5 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 395278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Villa 110 West Wissahickon Ave Flourtown, PA 19031 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 Employee E14 performed hand hygiene and put on clean gloves. She removed the soiled dressing from R39's right second toe, then she performed hand hygiene and put on clean gloves. She used a 4x4 soaked with saline to cleanse the wound. At this time, she did not perform hand hygiene and put on clean gloves. She used a cotton applicator to apply Santyl to the wound bed, applied a dry 2x2, and tape which had previously been labeled with the current date. Residents Affected - Few E14 performed hand hygiene and put on clean gloves. She removed the soiled dressing from R39's right heel, then she performed hand hygiene and put on clean gloves. She used a 4x4 soaked with saline to cleanse the wound. At this time, she did not perform hand hygiene and put on clean gloves. She then applied DermaGinate/Ag to the wound, covered it with and ABD and wrapped it with rolled gauze and secured it with tape labeled with the current date. Employee E14 performed hand hygiene and put on clean gloves. She removed the soiled dressing from the base of R39's left great toe, then she performed hand hygiene and put on clean gloves. She applied skin prep to the area and covered it with a foam dressing. At this time, she did not perform hand hygiene and put on clean gloves. Employee E14 removed the soiled dressing from R39's left heel, then she performed hand hygiene and put on clean gloves. She used a 4x4 soaked with saline to cleanse the wound, then performed hand hygiene and put on clean gloves. She then applied DermaGinate/Ag to the wound, covered it with an ABD and wrapped it with rolled gauze and secured it with tape labeled with the current date. Employee E14 gathered the trash and placed it in the waste basket, removed her gloves and placed them in the waste basket as well. She then removed the bag from the room and placed it in an appropriate receptacle and performed hand hygiene. As noted above, Employee E14 did not perform hand hygiene at four separate opportunities during wound care for Resident R39. The DermaGinate/Ag that was used was residual product from a package that had been previously opened and exposed to air. Alginate dressings should not be saved after opening as they absorb moisture from the air which can compromise their integrity. Also, once a sealed, single use package has been opened, any remaining product should be disposed of as exposure to the air and other surfaces can potentially introduce infectious agents to the product. Following wound care observations, interview with Licensed staff, Employee E14 on July 14, 2023 at 10:15 a.m. confirmed that she did not perform hand hygiene at the opportunities noted above. Interview with the Director of Nursing on July 14, 2023, 10:45 a.m. confirmed that the missed opportunities for hand hygiene by E14, as well as the use of dressings from a previously opened package constituted a breach in infection control practices. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395278 If continuation sheet Page 5 of 5