Inspection·May 23, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical records review and staff interview, it was determined that the facility failed to follow physician's order regarding insulin/blood sugar parameters and fluid restrictions for three of 22 residents reviewed (Residents 15, 58, and 87) Residents Affected - Few Findings include: Review of Resident 15's clinical record revealed diagnoses including but not limited to chronic kidney disease stage 3 (failure of kidney function to remove toxins from blood), diabetes type 2, heart disease and dementia (general loss of cognitive abilities, including memory). Review of Resident 15's physician order dated October 3, 2024 ,revealed an order for daily fluid restriction of 2000 ml daily as follows: Breakfast tray 540 ml; Free fluids day shift 400ml; Lunch tray 180 ml; Free fluids evening shift 600ml; Dinner tray 180ml; Free fluids Night shift 100ml. Review of Resident 15's Medication Administration Record (MAR) revealed no evidence of fluid monitoring. Interview with Director of Nursing on May 23, 2025, at approximately 10:30 am confirmed the above findings. A review of Resident 58's physician's order dated April 30, 2025, revealed an order for Insulin Lispro (A fast acting insulin)100 unit/ml Inject as per sliding scale: If 180-200 = 1 unit; 210-250 = 2 units; 251-300 = 3 units; 301-350 = 4 units; 351-400 = 5 units, subcutaneously before meals and at bedtime. Notify physician is blood sugar is below 70 or above 400. A review of the May 2025, Medication Administration Record (MAR) revealed a blood sugar of 64 on May 18, 2025, at 7:30 a.m. Clinical records review failed to reveal that the physician was notified of the above blood sugar result on May 18, 2025. A review of Resident 87's physician's order dated April 22, 2025, revealed an order for Insulin Glargine (A long-acting insulin) U 100 pen Inject 14 units subcutaneously one time a day hold for blood sugar less than 100. A review of Resident 87's May 2025, MAR revealed Insulin Glargine was administered out of parameters on the following dates: May 3, 2025, (99mg/dl); May 10, 2025, (83mg/dl); May 11, 2025, (86mg/dl); May 12, 2025, (93mg/dl). An interview with the Director of Nursing conducted on May 23, 2025, at 10:00 a.m., confirmed physician was not notified of Resident 58's blood sugar. The DON also confirmed Resident 87's insulin was administered outside of the ordered parameters on the dates mentioned above. The facility failed to ensure Residents 58 and 87's orders regarding insulin and blood sugar parameters were followed. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395332 If continuation sheet Page 2 of 3 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 395332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Center 30 West Avenue Wayne, PA 19087 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policy, observations, and interview with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the main kitchen area. Findings included: Review of facility policy, Food Storage: Cold Foods, revised February 2023, revealed that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observations in the main kitchen on May 20, 2025, at 9:20 a.m. in the presence of Employee E4 revealed uncovered scoops on top of the flour and sugar bins. Observations in the freezer during the same time frame revealed a bag of frozen green beans on the shelf with no label or date. Additionally, there were four frozen turkey burgers without a date. Observations in the walk-in refrigerator revealed ten 32 ounce containers of yogurt with a use by date of May 11, 2025. Observations in the dry storage room revealed a five pound open box of pancake mix with a use by date of March 25, 2025. Interview on May 20, 2025, during the kitchen tour with Employee E4, confirmed that the scoops should not have been stored uncovered on top of the bins, all items should be labeled and dated, and expired items should have been disposed. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.10(a) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395332 If continuation sheet Page 3 of 3