Health inspection·January 26, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive care plan for edema for one of 34 residents reviewed (Resident R140). Findings include: Resident R140 was admitted to the facility on [DATE], witht the diagnoses of hemiplegia (one sided paralysis) following cerebral infarction (stroke) affecting the left-dominant side and heart failure (heart does not pump sufficiently). Review of Resident R140's care plan revealed pain and general discomfort dated July 11, 2023, interventions included to assist the resident to a position or comfort using pillows or appropriate positioning devices and to place the resident's call bell within resident's reach. On January 22, 2023, at 1:15 p.m. during an interview Resident R140 stated he was very uncomfortable and his whole body hurt. He explained that his left side didn't work anymore because of a stroke. Part of his left lower arm was wrapped in gauze and the rest of his arm was swollen and red resting on a thin pad to collect drainage. The pad had scant tracings of yellowish stain mixed with what appeared to be blood. The resident indicated that they (staff) started wrapping his left arm because it was swollen and now the top of his arm looked worse and was painful. He couldn't adjust his arm himself and wanted staff assistants but his call bell was out of his reach. Review of Resident R140's physician orders dated January 11, 2023 Wound care treatment instructed to apply an ABD pad to left arm two times a day for seeping and as needed. Interview with Licensed Nurse, Employee E10 on January 22, 2023, at 1:38 a.m. stated Resident R140's left arm should be wrapped and elevated on pillows due to his edema. This was confirmed with the Assistant Director of Nursing on January 22, 2024 at 3;00 p.m. that the facility failed to develop a care plan for Resident R140's left arm edema related to the fluid imbalance due to heart disease with interventions to elevate and wrap left arm. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 2 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of resident's clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure physician's wound care recommendations to prevent pressure injuries were followed for one of four residents reviewed with pressure ulcers (Resident R150). Residents Affected - Few Findings include: Review of the facility's policy titled Wound Prevention and Management, not dated, stated that each resident receives the care and services necessary to retain or regain optimal skin integrity. Residents identified as a risk for development of pressure ulcers will have a plan and interventions included in the care plan to address risk factors for development of pressure ulcers. Orders/changes to the treatment will be documented and the care plan will be updated to aide in healing and prevent further breakdown based upon the co-morbidities and the risk factors associated with the resident. Implementation of relevant treatment and preventative measures will be implemented should impaired skin be discovered per provider recommendation. Review of Resident R150's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of with cerebral infarction (stroke) and hemiplegia (paralysis on one side of the body). Review of Resident R150 admission MDS (minimum Data Set-an assessment of resident's needs) dated September 22, 2023, indicated the resident had severe cognitive impairment, incontinent of urine and bowel, used a wheelchair for ambulating and needed extensive assistance of two people with bed mobility, transfers, personal hygiene, and toileting. Review of R150's initial wound consult, dated September 19, 2023, assessed the resident for a callous (thickened skin caused by friction) on her left foot, present on admission. The specialist noted the resident with weakness, left sided hemiplegia and a history of a sacral pressure ulcer (stage not indicated). The wound specialist assessment determined the resident was a high risk for pressure injury due to the resident's decreased mobility, the severe contractures on the lower left extremity, incontinence and a previous history of a pressure ulcer. The specialist stated, If found to have poor bed mobility, would recommend the use of a low air loss mattress (the mattress keeps pressure off of bony areas in patients unable to reposition themselves to prevent pressure ulceration). Nursing progress note dated September 20, 2023 from the Assistant Director of Nursing, (ADON), indicated Resident R150 was seen by the wound specialist treatment orders in place. Further review of Resident R150 clinical record revealed the facility failed to follow the wound specialist recommendation and a low air loss mattress was not provided to Resident R150. Review of Resident R150's care plan, dated September 15, 2023, revealed the resident was not able to perform her activities of daily living due to her left sided weakness and immobility. Interventions included two people assisting with transfers, a staff member to assist the resident with bed and wheelchair positioning, and toileting. Further review of the care plan revealed the resident was at risk for pressure injuries, due to her limited mobility, pain, weight loss and impaired skin dated September 18, 2023 and was a fall risk due to her decreased mobility, and safety awareness, dated September 19, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 3 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 Residents Affected - Few On November 30, 2023 facility documentation revealed an open area was found on Resident R150's left buttock measuring 3.0 cm x 3.0 cm. Orders for the low air loss alternating mattress for wound prevention originally recommended by the wound specialist on September 19, 2023, was now placed on December 1, 2023, for wound healing. Review of the wound specialist note dated, December 7, 2023, assessed Resident R150's wound as a Stage Three Pressure Ulcer (Full thickness tissue loss with subcutaneous fat or slough present), on the resident's left ischium with 50% slough (dead tissue) and serosanguineous drainage (clear fluid mixed with blood). The wound specialist determined that the wounds were unavoidable due to the interventions already in place. Observation of Resident R150's wound care was conducted on January 24, 2023, at 11:44 a.m. with Registered Nurse (RN) Employee E5 and RN Employee E21. Resident R151's lower extremities was observed contracted, while RN, Employee E21 positioned and held the resident in bed for wound care. Wound dressing was observed with thick greenish/ milky white drainage. Wound note from the wound specialist dated January 23, 2023, noted the wound measurement 4 cm x 3.8 cm x 2 cm deep with 3 cm undermining at 12 o'clock and 3 o'clock. Interview with the Assistant Director of Nursing (ADON) on January 26, 2024, at 2:15 p.m., confirmed the wound consultant was not aware the air mattress was not in place during the December 7, 2023, wound assessment. The ADON stated that on admission felt Resident R150 did not have poor bed mobility and the air mattress was not needed. Indicated the interventions on admission included a barrier cream (the facility's standard topical treatment) for wound prevention while in bed and a cushion on the wheelchair. Review of the Physical Therapy (PT) notes revealed on admission the resident was Dependent on staff for bed mobility dated September 16, 2023 and September 27, 2023, PT noted the resident required Substantial/maximal assistance. Furthermore the resident's care plan was revised on December 7, 2023 to include turning and repositioning the resident every two hours in bed. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 4 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of professional literature, review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide appropriate assistance while providing incontinence care to a resident, resulting in actual harm to Resident R215 who rolled off the bed and sustained head injuries, including an acute right subdural hemorrhage, left diffuse subdural hematoma, right-to-left midline shift and right uncal herniation and subsequence death for one of six residents reviewed. This deficiency was cited as past-noncompliance. (Resident R215) Findings include: Review of professional literature, published by the American Congress of Rehabilitation Medicine and the Archives of Physical Medicine and Rehabilitation, Caregiver Guide and Instructions for Safe Bed Mobility article 2017;98:1907-10, revealed, The term bed mobility refers to activities such as scooting in bed, rolling (turning from lying on one's back to side-lying), side-lying to sitting, and sitting to lying down. Continued review revealed, The patient should always roll toward you not away from you. Review of Resident R215's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated [DATE], revealed that the resident was admitted to the facility on [DATE], with diagnoses including heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), Parkinson's Disease (a progressive disorder of the nervous system that affects movement) and hydrocephalus (a build-up of fluid in the brain). Continued review revealed that the resident was severely cognitively impaired and that the resident was dependent for rolling left and right. Review of Resident R215's care plan, dated initiated [DATE], revealed that the resident had decreased ability to perform activities of daily living due to immobility and Parkinson's disease. Interventions included 2 person assist that was initiated on February 23, 2022, as well as The resident requires assistance with positioning in bed that was initiated on [DATE]. Review of Medication Administration Records (MARs) for Resident R215 for [DATE], revealed a physician's order, dated [DATE], for an air mattress to the resident's bed. The MARs indicated that the air mattress was checked by licensed nursing staff every shift for proper function and setting. Review of progress notes for Resident R215 revealed a note, dated [DATE], at 8:42 p.m. which stated, While CNA [nurse aide] was performing care resident rolled oob [out of bed] and sustained laceration to back of head. The resident was subsequently transferred to a local hospital emergency department for further evaluation. Continued review of progress notes for Resident R215 revealed a note, dated [DATE], at 4:21 a.m. which indicated that the resident was admitted to the hospital with a diagnosis of intracranial hemorrhage (brain bleed). Further review of progress notes for Resident R215 revealed a note, dated [DATE], at 12:27 p.m. which indicated that the facility received a call from the hospital that the resident passed away at 11:47 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 5 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of hospital records for Resident R215 revealed a CT scan (diagnostic testing) study result, dated [DATE], at 10:51 p.m. which indicated, There is an acute subdural hemorrhage (bleeding between the skull and the surface of the brain) over the right temporoparietal and occipital (back of the brain) regions. This measures up to 4 mm (millimeters) in thickness. No significant mass-effect (shifting of brain tissue) is noted. There is also a linear area of high density in the right sylvian fissure (divides the temporal [left and right sides of the brain] from the parietal [midbrain] and frontal [font of the brain] lobes of the brain) consistent with subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) .There is a ventriculoperitoneal shunt (drains excess fluid in the brain, used to treat hydrocephalus) in the right posterior region .no hydrocephalus. Continued review of hospital records for Resident R215 revealed another CT scan study result, dated [DATE], at 2:38 a.m. which indicated, Significant increase in right subdural hematoma that measures up to 2.8 cm (centimeters) from previous 5 mm. New diffuse left subdural hematoma that measures up to 5 mm. Right-to-left midline shift (displacement of brain tissue across the center line of the brain) by 6.5 mm. New right uncal herniation (parts of the brain move from one intracranial compartment to another, it is a life-threatening neurological emergency). Increase in right frontal temporal subdural hemorrhage . Stable intraventricular shunt. Further review of hospital records revealed a neurosurgery (medical specialist related to brain disorders) note, dated [DATE], at 9:47 a.m. which stated, Nursing home patient with advanced dementia and limited function. Reportedly to have fallen at living facility. Initial CT head showed nonsurgical small right-sided subdural hematoma. Repeat imaging with significant expansion. Goals of care clarified with family in early morning regarding baseline status. Family chose not to pursue surgical options through the night although patient remained full code. Patient coded and expired. Non salvageable and expanding acute subdural hematoma with significant mass effect and shift. Review of facility documentation submitted to the Pennsylvania Department of Health on [DATE], at 1:59 p.m. revealed that Resident R215 had a fall out of bed during incontinence care. Continued review of facility documentation revealed a written statement by Employee E20, occupational therapist, which stated, Resident was seen for skilled occupational therapy from [DATE]-[DATE]. At the time of discharge, [Resident R215] was an assist of 1 [one person] for rolling side to side. Continued review of facility documentation revealed a written statement by Employee E9, agency nurse aide, which stated, I was changing [Resident R215] when I was putting the clean bed chuck under her, she rolled over as I was tucking the chuck under her and briefly moved to fix that's when she rolled to floor. I tried to catch her but I didn't have enough reach to do so. Interview on [DATE], at 12:38 p.m. with the Director of Nursing (DON) and Employee E21, licensed nurse, revealed that the facility investigated the incident and did a re-enactment with the Employee E9, agency nurse aide. Employee E21, licensed nurse, stated that Employee E9, agency nurse aide, pulled Resident R215 closer to her, then turned the resident on her side. Employee E21, licensed nurse, confirmed that Employee E9, agency nurse aide, turned Resident R215 away from her while turning the resident in the bed. Resident R215 subsequently rolled off the side of the bed. The DON stated that it is the policy of the facility to always turn a resident towards you when turning a resident in bed. Employee E21, licensed nurse, stated that she was not sure what type of training agency staff received and stated that she gives nurse aides verbal reports at the beginning of their shift. The DON stated that she would have to ask the facility's nurse educator to explain what type of training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 6 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 0689 agency staff receive. Level of Harm - Actual harm Interview on [DATE], at 12:53 p.m. Employee E22, nurse educator, stated that according to the facility's training regarding safe patient bed mobility, residents should always be rolled toward the caregiver when turning them in bed. In addition, Employee E22, nurse educator, stated that she does not do any type of skills trainings or skills competency evaluations for agency staff. Residents Affected - Few Employee E22, nurse educator, subsequently provided facility document, ADLs [Activities of Daily Living]: Turn and Reposition/Bed Mobility undated, which states under procedure, Resident is turned towards staff member if 1-person assist. Review of Employee E9, agency nurse aide, personnel file, revealed that she was employed as an agency nurse aide by the facility. Continued review revealed that no skills competency evaluations were available for review at the time of the survey. Interview on [DATE], at 1:13 p.m. Employee E22, nurse educator, confirmed that there were no skills competency evaluations for Employee E9, agency nurse aide. Interview on [DATE], at 2:25 p.m. Employee E9, agency nurse aide, stated that she recalled Resident R215 and the incident that occurred. She stated that it was a horrible incident and that the resident had no perimeter mattress, no siderails, nothing along the edges of the air mattress to keep the resident from rolling off. Employee E9, agency nurse aide, stated that while she was tucking the chuck during incontinence care for Resident R215 that she moved the resident away from her, the resident moved and rolled off the bed. Employee E9, agency nurse aide, stated that more could have been done to prevent the fall from occurring, such as having bedrails, a perimeter mattress or a wedge in place. Employee E9, agency nurse aide, stated that she already provided a written statement, as well as performed a re-enactment of the event, and to refer to those documents for this investigation. Interview on [DATE], at 4:42 p.m. with Employee E19, Medical Director, revealed that Resident R215's ventriculoperitoneal shunt was functioning appropriately according to the hospital CT scans and agreed that the scans showed acute injuries that were caused by the resident's fall. This deficiency was identified as actual harm past non-compliance for failure to provide appropriate assistance while providing incontinence care to Resident R215, resulting in the resident rolling off the bed and sustaining serious head injuries. On [DATE], at 1:12 p.m. the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on [DATE], to address the failure to provide appropriate assistance during incontinence care, which resulted in Resident R215 falling off the bed and sustaining serious head injuries which lead to the resident's death. Facility plan of correction included the following: [DATE] Resident fall occurred statements obtained. Resident sent to emergency department for evaluation. The investigation immediately began. [DATE]-[DATE] DON and Administrator reviewed statements obtained, more questions were needed from employees involved. Event report submitted to Department of Health. [DATE] DON reviewed residents on nurse aide's assignment to review if any significant incidents had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 7 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 0689 occurred. None were identified. Level of Harm - Actual harm [DATE] Nurse taking care of resident brought in to look at room and demonstrate how resident was positioned on the floor. Regional Nurse and DON were present for the demonstration. Residents Affected - Few [DATE] Facility completed review of residents who are an assist of one for bed mobility with nursing and therapy, if changes were identified as being needed, care plans were updated. Residents who were on air mattresses were care planned for an assist of two for bed mobility. Nurse aide providing care to resident was brought in to reenact what took place and contracted employee provided care according to resident's care card. [DATE] Incidents were reviewed for dates nurse aide worked between [DATE] - [DATE], no residents on nurse aide's assignment on dates worked in that timeframe had any incident. Education and competencies were completed between [DATE] - [DATE] with staff and agency staff on Turn/ADL/Bed Mobility. Medical Director reviewed case and gave input. Event report updated and accepted. The facility alleged compliance with their plan of correction as of [DATE]. Review of facility documentation revealed that the corrective action plan was initiated on [DATE]. Residents on nurse aide's assignment were reviewed and no other incidents were noted. Dates that nurse aide worked were reviewed with no incidents noted. A full house audit of resident care plans for bed mobility status was completed. Competency evaluations related to bed mobility were completed [DATE] through 22, 2023. Interviews with nursing staff confirmed that they were knowledgeable of the facility's bed mobility practices. Falls were reviewed during morning meeting to ensure that appropriate assistance was provided. Thirty-day review of falls was completed and appropriate assistance was provided. Care plan audit completed with interventions in place to ensure appropriate bed mobility assistance. 28 Pa Code 201.14(a)Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 8 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on interviews with residents and staff and observations of the food and nutrition services, a meal tray evaluation and reviews of facility policies and procedures, it was determined that the facility failed to ensure that foods were served palatable and at proper temperature (Residents R6, R14 and R98). Residents Affected - Some Findings include: Areview of the facility policy titled Test Tray Evaluation dated January, 2023 revealed that the acceptable temperature for the foods at point of service to the residents was 135 degrees Fahrenheit. Interview on January 22, 2024, at 10:58 a.m. Resident R14 stated that sometimes the food was served cold. Interview on January 22, 2024, at 11:08 a.m. Resident R98 stated that foods and coffee were served too cold. Observation during the luncheon meal on January 22, 2024, at 12:52 p.m. Resident R98 stated that his lunch tray was cold and that it could be served warmer. During a group meeting with residents on January 24, 2024, at 10:30 a.m. Resident R6 stated that her breakfast was served cold. Obsservations inside the main kitchen on January 23, 2024, of the preparation of foods and beverages for delivery to the nursing units revealed that an essential piece of food service equipment was not functioning. The plate warmer was cold to touch. The malfunctioning plate warming device was confirmed with the director of dietary services, Employee E4, at 11:30 a.m., on January 23, 2024. A meal tray evaluation completed with the director of dietary services, Employee E4, during the noon meal service on the C Wing nursing unit on January 24, 2024. The menu indicated that stuffed shells with sauce, broccoli florets, garlic bread, whole milk, cookies, and a beverage of coffee was served. The test tray evaluation was done during the point of service, of the foods and fluids for the residents. The stuffed shells were served below 135 degrees Fahrenheit at 116 degrees Fahrenheit, coffee was tested at 116 degrees Fahrenheit, which was below the established hot beverage serving temperature of 135 degrees Fahrenheit. Broccoli florets were served at 102 degrees Fahrenheit, which was below the temperature for hot foods that was 135 degrees Fahrenheit. The stuffed shells lacked sauce. The menu called for two ounces of sauce. The garlic bread was two slices of white bread with margarine and garlic powder. The recipe called for Italian bread. The two chocolate chip cookies were boxed, not homemade or baked at the facility. 28 PA. Code 201.18(b)(1)(3) Management 28 PA. Code 211.10(a)(c)(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 9 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations of the Food and Nutrition Services Department, reviews of policies and procedures and interviews with staff, it was determined that foods and fluids were not being stored, prepared, delivered and served under sanitary conditions to meet professional standards of food service safety. Findings include: A review of the policies titled sanitizing food surfaces and equipment cleaning dated October 2022, revealed that it was the responsibility of the dietary staff to ensure that food contact surfaces were maintained clean and sanitary in the main kitchen. The policies also indicated that dietary staff were also responsible for maintaining all food service equipment clean and sanitary to prevent a food safety hazard. Observations made between 9:00 a.m. and 12:30 p.m., on January 22, 2024, of the main kitchen, of the food and nutrition department, where foods and beverages are stored, prepared and served for the residents revealed that procedures were not being followed in the food preparation and servining process to reduce, eliminate or prevent the possiblity of a food safety hazard. Observations at 9:00 a.m., on Janaury 22, 2024 with the director of dietary services, Employee E4 and the registered dietitian, Employee E3 revealed that the flooring throughout the main kitchen had been removed leaving a heavy accumulation of dirt, dust, cement, food debris, food spillage, discarded paper and mud in the the hot and cold food preparation and cooking areas. Dietary staff were observed preparing and assembling foods and beverages on the tray line to transport to the nursing units for the residents. Observations revealed a section of the main kitchen that contained new ceramic floor tiles; however there was no grouting placed to complete and seal the installation. In this area, a heavy accumulation of dirt and food debris was noted in the deep gaps surrounding the ceramic tiles. Observations in the dish room and three compartment sink area revealed a continuation of dirt and food debris build-up, with an additional sink leaking water surrounding the three compartment sink. The director of dietary reported that a new three compartment sink was slated to be installed after the flooring was replaced. The director of dietary services also reported that the working mechaniasms underneath the sink were rusted and worn away giving way to the pooling of water throughout the dish room area. Sludge and oil droplets were evident on the flooring in the area. Dietary staff were noted washing dishes, utensils, pots, pans, cups, mugs, then placing the cleaned food service equipment onto open racks, carts and mobile units in the dish room and three compartment sink area; where the flooring had been demolished. Interview with the Nursing Home Administrator at 1:00 p.m., on January 22, 2024 confirmed that the destruction of the kitchen flooring had begun on January 15, 2024. Further interview with the administrator confirmed the lack of dietary staff, following professional standards for food service safety and preventing the contamination of foods and beverages; while the flooring was being constructed throughout the main kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 10 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 Observations of the main kitchen with the director of dietary services on January 23, 2023 revealed that ceiling light fixtures were missing light bulbs and that lighting was dull throughout the dietary department. The dish room and three compartment sink area contained a black substance resembling mold, that was noted behind the sinks, wall area and ceiling. Residents Affected - Many The the three compartment sinks faucets were constantly leaking and spraying water on the wall area inside the dish room. The mechanics underneath the three compartment sink were rusted and water damaged not allowing proper operation. The sinks were not consistantly holding water, leaking onto the floor. The walk-in refrigerator shelving, walls and floors contained a build-up of food spillage and debris. The threshold of the doors leading directly out onto the loading dock was not sealing properly. There was a two inch gap at the bottom of the door allowing easy access into the building for pests and rodents. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 205.13(b) Floors FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 11 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to the failure to provide appropriate assistance during incontinence care to Resident R215, resulting in the resident rolling off the bed and sustaining serious head injuries, which resulted in an Immediate Jeopardy situation. Residents Affected - Few Findings include: Review of the job description for the Nursing Home Administrator revealed, The Nursing Home Administrator (NHA) assumes full-time administrative authority, responsibility and accountability for the operations and for the financial viability of the nursing facility. Manages facility employees in the provision of care and services rendered in accord with professional standards, and in compliance with state and federal laws and regulations. Review of the job description for the Director of Nursing revealed that the primary purpose of the position, is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Center . to ensure that the highest degree of quality care is maintained at all times. Review of Resident R215's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated [DATE], revealed that the resident was admitted to the facility on [DATE], with diagnoses including heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), Parkinson's Disease (a progressive disorder of the nervous system that affects movement) and hydrocephalus (a build-up of fluid in the brain). Continued review revealed that the resident was severely cognitively impaired and that the resident was dependent for rolling left and right. Review of Resident R215's care plan, dated initiated [DATE], revealed that the resident had decreased ability to perform activities of daily living due to immobility and Parkinson's disease. Interventions included 2 person assist that was initiated on February 23, 2022, as well as The resident requires assistance with positioning in bed that was initiated on [DATE]. Review of Medication Administration Records (MARs) for Resident R215 for [DATE] revealed a physician's order, dated [DATE], for an air mattress to the resident's bed. The MARs indicated that the air mattress was checked by licensed nursing staff every shift for proper function and setting. Review of progress notes for Resident R215 revealed a note, dated [DATE], at 8:42 p.m. which stated, While CNA [nurse aide] was performing care resident rolled oob [out of bed] and sustained laceration to back of head. The resident was subsequently transferred to a local hospital emergency department for further evaluation. Continued review of progress notes for Resident R215 revealed a note, dated [DATE], at 4:21 a.m. which indicated that the resident was admitted to the hospital with a diagnosis of intracranial hemorrhage (brain bleed). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 12 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of progress notes for Resident R215 revealed a note, dated [DATE], at 12:27 p.m. which indicated that the facility received a call from the hospital that the resident passed away at 11:47 a.m. Review of hospital records for Resident R215 revealed a CT scan (diagnostic testing) study result, dated [DATE], at 10:51 p.m. which indicated, There is an acute subdural hemorrhage (bleeding between the skull and the surface of the brain) over the right temporoparietal and occipital (back of the brain) regions. This measures up to 4 mm (millimeters) in thickness. No significant mass-effect (shifting of brain tissue) is noted. There is also a linear area of high density in the right sylvian fissure (divides the temporal [left and right sides of the brain] from the parietal [midbrain] and frontal [font of the brain] lobes of the brain) consistent with subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) .There is a ventriculoperitoneal shunt (drains excess fluid in the brain, used to treat hydrocephalus) in the right posterior region .no hydrocephalus. Continued review of hospital records for Resident R215 revealed another CT scan study result, dated [DATE], at 2:38 a.m. which indicated, Significant increase in right subdural hematoma that measures up to 2.8 cm (centimeters) from previous 5 mm. New diffuse left subdural hematoma that measures up to 5 mm. Right-to-left midline shift (displacement of brain tissue across the center line of the brain) by 6.5 mm. New right uncal herniation (parts of the brain move from one intracranial compartment to another, it is a life-threatening neurological emergency). Increase in right frontal temporal subdural hemorrhage . Stable intraventricular shunt. Further review of hospital records revealed a neurosurgery (medical specialist related to brain disorders) note, dated [DATE], at 9:47 a.m. which stated, Nursing home patient with advanced dementia and limited function. Reportedly to have fallen at living facility. Initial CT head showed nonsurgical small right-sided subdural hematoma. Repeat imaging with significant expansion. Goals of care clarified with family in early morning regarding baseline status. Family chose not to pursue surgical options through the night although patient remained full code. Patient coded and expired. Non salvageable and expanding acute subdural hematoma with significant mass effect and shift. Review of facility documentation submitted to the Pennsylvania Department of Health on [DATE], at 1:59 p.m. revealed that Resident R215 had a fall out of bed during incontinence care. Continued review of facility documentation revealed a written statement by Employee E9, agency nurse aide, which stated, I was changing [Resident R215] when I was putting the clean bed chuck under her, she rolled over as I was tucking the chuck under her and briefly moved to fix that's when she rolled to floor. I tried to catch her but I didn't have enough reach to do so. Interview on [DATE], at 12:38 p.m. with the Director of Nursing (DON) and Employee E21, licensed nurse, revealed that the facility investigated the incident and did a reenactment with the Employee E9, agency nurse aide. Employee E21, licensed nurse, stated that Employee E9, agency nurse aide, pulled Resident R215 closer to her, then turned the resident on her side. Employee E21, licensed nurse, confirmed that Employee E9, agency nurse aide, turned Resident R215 away from her while turning the resident in the bed. Resident R215 subsequently rolled off the side of the bed. The DON stated that it is the policy of the facility to always turn a resident towards you when turning a resident in bed. Interview on [DATE], at 2:25 p.m. Employee E9, agency nurse aide, stated that she recalled Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 13 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R215 and the incident that occurred. She stated that it was a horrible incident and that the resident had no perimeter mattress, no siderails, nothing along the edges of the air mattress to keep the resident from rolling off. Employee E9, agency nurse aide, stated that while she was tucking the chuck during incontinence care for Resident R215 that she moved the resident away from her, the resident moved and rolled off the bed. Employee E9, agency nurse aide, stated that more could have been done to prevent the fall from occurring, such as having bedrails, a perimeter mattress or a wedge in place. Employee E9, agency nurse aide, stated that she already provided a written statement, as well as performed a reenactment of the event, and to refer to those documents for this investigation. Interview on [DATE], at 4:42 p.m. with Employee E19, medical director, revealed that Resident R215's ventriculoperitoneal shunt was functioning appropriately according to the hospital CT scans and agreed that the scans showed acute injuries that were caused by the resident's fall. Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate jeopardy situation. Refer to F689. 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 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 14 of 15 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 395479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gwynedd Healthcare and Rehabilitation Center 773 Sumneytown Pike Lansdale, PA 19446 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on reviews of facility policies and procedures, observations of the main kitchen of the food and nutrition department, the garbage and refuse area and the pest control operators reports, it was determined that the facility failed to maintain an effective pest control program so that the interior of the building was pest free. Residents Affected - Few Findings include: A review of the policy titled Pest Control dated May, 2008 revealed that it was the responsibility of the facility to ensure that the facility was free of insects and rodents by having an effective pest control program. The policy also indicated that garbage was not permitted to accumulate on the premises. Observations of the hall way outside the food and nutrition department revealed that the threshold of the double doors, upon closing were not sealed properly. When opened, the doors lead directly outside the building, onto the loading dock. Observations at the threshold of the double doors upon closing evidenced a two inch gap. This opening located at the bottom of the doors allowed easy access into the building for common household pests and rodents. Further observations of the loading/receiving dock revealed that adjacent to this area was the dumpster and trash and refuse compactor. Placed directly on the driveway and below the loading and receiving dock were ten plastic bags full of trash and refuse. The ten bags of trash and refuse were not contained in garbage recepticles with lids to prevent pest and rodent harborage, nesting and breeding. Observations of the trash and refuse area revealed that eight used wooden pallets were propped against the side of the dumpster/compactor unit. Providing a place for pests to live and breed. The pest control operators reports were reviewed for November, 2023 December, 2023 and January, 2024. The pest control reports revealed that the kitchen was being treated for common house hold pests(mice, roaches) during these three months. Interview with the Nursing Home Administrator, at 10:00 a.m., on January 23, 2024 confirmed the lack of effective pest control for the facility during the months of November, 2023, December , 2023 and January, 2024. 28 Pa. Code 201.18(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395479 If continuation sheet Page 15 of 15