Health inspection·August 22, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to two dining rooms observed. (First Floor and Second Floor dining rooms.) Findings include: Review of facility policy titled, Resident Rights Under Federal Law revised February 1, 2023, indicated that the facility must treat each resident with respect and dignity and care for each resident in a manner and an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. Interview with Resident R1 on August 21, 2023, at 10:10 a.m. revealed meals do not arrive timely and that residents were not served at one time, you just sit there and watch someone else eat. Observations of the First-floor dining room on August 21, 2023, at 12:15 p.m. revealed the following: A table of three residents, only one resident was served a meal. Further observations revealed a resident walked into the dining room to be seated and was told there was no more room available for her to sit. Employee E14 stated, someone will get up soon, come back a little later. Interview held with the Speech Pathologist, Employee E14, at 12:20 p.m. confirmed that the first-floor dining room never has enough room to seat all residents. Observations of the second-floor dining conducted on August 21, 2023, at 12:35 p.m. revealed the following: A table of two residents; one resident was served a meal at 12:37 p.m. This resident ate his meal and left the dining room at 12:49 p.m. The second resident received his meal seventeen minutes later, at 12:54 p.m. A table of three resident; one resident was served a meal at12:37 p.m.; another resident was served at 12:47 p.m.; the last resident was served at 12:54 p.m. Further observations revealed Resident R11 attempting to leave the dining room. Interview with Page 1 of 8 395481 395481 08/22/2023 Hillcrest Center 1245 Church Road Wyncote, PA 19095

F 0550 resident R11 at 12:43 p.m. revealed lunch meals never come on time and it's worse now. Level of Harm - Minimal harm or potential for actual harm Interview with the Food Service Department team on August 21, at approximately 3:00 p.m. confirmed the above-mentioned findings. Residents Affected - Some 28 Pa. Code 201.29(d) Resident Rights 395481 Page 2 of 8 395481 08/22/2023 Hillcrest Center 1245 Church Road Wyncote, PA 19095

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to provide written notice, including reason for transfer before a resident's room was change for one of 12 residents reviewed (Resident R10). Findings Include: A review of facility policy titled, Room transfers revised August 7, 2023, revealed Notification of room change, or new roommate will be provided within reasonable/required time frames . If the room change is facility initiated and the patient agrees to transfer, the facility must give the resident or resident representative as much notice as possible including an explanation of the reason for the move. The facility must provide an opportunity for the resident or resident representative to see the location and meet the new roommate. Review of Resident R10's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated June 15, 2023, revealed Resident R10 was admitted to the facility on [DATE], with diagnoses including mild cognitive impairment, cognitive communication deficit, anxiety, and depression. Review of Resident's BIMS (Brief Interview for Mental Status) revealed resident had severely impaired cognition. Resident R10's clinical record indicated that her son was her power of attorney. Clinical record review for Resident R10 revealed a Social Services note dated August 18, 2023, at 3:43 p.m. which indicated that placed a telephone call to residents' son after speaking with resident regarding a room change, resident was made aware that a window bed is available which resident was an agreement with and so was her son. Continued record review for resident R10 revealed another Social Services note dated August 21, 2023, at 3:43 p.m. which indicated that Resident R10's family is upset with the room change that took place on Friday 8/18/2023. Resident R10's son explained that he was not notified that the room would be at the end of the hallway, and that he would like his mother's room to be changed closer to the front as he is unable to walk a far distance. Interview conducted on August 23, 2023, at 1:19 p.m. with Social Services Director, Employee E12, revealed that the change was initiated due to a new admission hesitated to come to a full bedded room. Further interview revealed that the social worker should have explained and documented the reason of the initiated room change prior to making the change. This interview confirmed that Resident R10 and their representative was not provided with reason of room change per policy. Employee E12 also confirmed that the resident and their representative were not provided with a chance to see the new room or meet her new roommates. Resident R10's power of attorney did not receive a written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. Observations of Resident R10's room [ROOM NUMBER], prior to her room change, revealed Resident R10's belongings were in plastic bags on the nightstand while Resident R10 was residing in room [ROOM NUMBER]. 395481 Page 3 of 8 395481 08/22/2023 Hillcrest Center 1245 Church Road Wyncote, PA 19095

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Resident R10 conducted on August 22, 2023, at 1:57 p.m. in room [ROOM NUMBER], Resident R10 stated, I want to go home, please take me home. Resident was observed crying, shaking, and emotionally upset. Interview with Unit Manager, Employee E13, on August 22, 2023, at 3:00 p.m. confirmed that Resident R10 was not transferred prior to this transfer dated August 18, 2023. 28 Pa. Code 201.14(a) Responsibility of licensee 29 Pa. Code 201.29(d) Resident rights 29 Pa. Code 201.29(j) Resident rights 395481 Page 4 of 8 395481 08/22/2023 Hillcrest Center 1245 Church Road Wyncote, PA 19095

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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet care needs for two of 12 residents reviewed. (Resident R10, R1) Findings include: Review of facility policy titled, Person- Centered Care Plan revised October 24, 2022, revealed that the Care plan will be created for each resident to attain or maintain the patient's highest practicable physical, mental and psychosocial wellbeing and to To eliminate or mitigate triggers that may cause re-traumatization of the patient. The care plan must be customized to each individual patient's preferences and needs. Review of Resident R10's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated June 15, 2023, revealed Resident R10 was admitted to the facility on [DATE], with diagnoses including mild cognitive impairment, cognitive communication deficit, anxiety, and depression. Review of Resident's BIMS (Brief Interview for Mental Status) revealed resident had severely impaired cognition. Resident R10's clinical record indicated that her son was her power of attorney. Clinical record review for Resident R10 revealed a Social Services note dated August 18, 2023, at 3:43 p.m. which indicated that placed a telephone call to residents' son after speaking with resident regarding a room change, resident was made aware that a window bed is available which resident was an agreement with and so was her son. Continued record review for resident R10 revealed another Social Services note dated August 21, 2023, at 3:43 p.m. which indicated that Resident R10's family is upset with the room change that took place on Friday 8/18/2023. Resident R10's son explained that he was not notified that the room would be at the end of the hallway, and that he would like his mother's room to be changed closer to the front as he is unable to walk a far distance. Interview conducted on August 23, 2023, at 1:19 p.m. with Social Services Director, Employee E12, revealed that the change was initiated due to a new admission hesitated to come to a full bedded room. Further interview revealed resident was very upset with her new room. Interview with Resident R10 conducted on August 22, 2023, at 1:57 p.m. Resident R10 stated, I want to go home, please take me home. Resident was observed crying, shaking, and emotionally upset. Review of Resident R10's clinical record revealed no documented evidence a comprehensive care plan was developed for Resident's R10 regarding resident had difficult time adjusting to her new room status post room change. During and interview with Resident R1 conducted on August 21, 2023, at 10:10 a.m. resident stated, I prefer a vegetarian diet. Further interview revealed she followed a vegetarian diet since admission. Resident R1 stated she had voiced her preferences to the Registered Dietitian upon admission. 395481 Page 5 of 8 395481 08/22/2023 Hillcrest Center 1245 Church Road Wyncote, PA 19095

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of Resident R1's Quarterly MDS dated [DATE], revealed Resident R1 was admitted to the facility on [DATE], with diagnoses including dysphasia (difficulty to swallow), gastroparesis (a disorder that slows or stops the movement of food from your stomach to your small intestine), and gastroesophageal reflux disease (a condition in which the stomach contents move up into the esophagus). Review of Resident's BIMS revealed resident was cognitively intact. Residents Affected - Few Review of Resident R1's clinical records revealed a note by the Registered Dietitian on July 24, 2020, which indicated that resident was in fact following a vegetarian diet, Selects meals and prefers to Vegetarian diet usually. Another note by the Registered Dietitian on November 16, 2022, revealed that the resident received the preferred Vegetarian burger with vegetables but stated to writer I always get this and fish. Review of Resident R1's clinical record revealed no documented evidence a comprehensive care plan was developed for Resident's R1 regarding her preference of eating a vegetarian diet. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395481 Page 6 of 8 395481 08/22/2023 Hillcrest Center 1245 Church Road Wyncote, PA 19095

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 observations of the Food and Nutrition Services, reviews of policies and procedures, and interviews with residents, it was determined that the facility failed to ensure that each resident received foods and beverages that were at appetizing temperatures. Residents Affected - Few Findings include: Review of the facility policy titled, Time and Temperature Control and Recording revised September 2017, revealed, bacteria and other foodborne pathogens can grow quickly in the temperature Danger Zone of 41-135 degrees Fahrenheit . Proper holding and transport of food is critical for resident safety and wellness. Further review, under the section titled Transporting, revealed, that all hot foods must be maintained at 135 degrees Fahrenheit or above and that all cold foods are maintained at 41 degrees Fahrenheit to minimize opportunities for bacterial growth. Observations of the tray line conducted on August 21, 2023, at approximately 1:00 p.m. revealed the salad container was not cooled/iced on the tray line to maintain proper cold holding procedures and ensure food safety. On August 21, 2023, at 1:30 p.m. a Test Tray was conducted in the presence of the Assistant Food Service Manager, Employee E7, which revealed that the temperatures of the cold foods tested were in the Danger Zone of 41-145 degrees Fahrenheit. The ham and cheese sandwich registered at 62.4 degrees Fahrenheit; lettuce and tomato at 64 degrees Fahrenheit; fruit cocktail at 56.3 degrees F; and juice at 43.9 degrees Fahrenheit. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services 395481 Page 7 of 8 395481 08/22/2023 Hillcrest Center 1245 Church Road Wyncote, PA 19095

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 review of facility documentation, review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to maintain complete clinical records for one of 12 residents reviewed (Resident R12). Findings Include: A review of facility policy titled, Elopement of Patient revised September 24, 2022, indicated that all Elopement Risk Identification forms for residents at risk of elopement must be current. Residents will be evaluated for elopement risk with change in condition. The elopement investigation to be completed within five days. Review of the Facility Elopement Investigation Report, dated, August 10, 2023, indicated that Resident R12 was observed by the supervisor ambulating independently outside in the front of the building. Resident is severely cognitively impaired, identified as an elopement risk with wanderguard in place and functioning . Upon return to her room staff noted that the window screen was pushed out & the window open approximately 10. Resident weight is 80 pounds. Window was closed & secured; the maintenance director checked the window & identified the stop brackets to be bent & loose allowing the window to open to 8-10. Per maintenance director it appeared the window was forced up causing the brackets to bend. A review of Resident R12's Comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 7, 2023, revealed the resident was admitted on [DATE], and had diagnoses including Alzheimer's Dementia (range of conditions that affect the brain's ability to think, remember, and function normally). Further review of Resident R12's clinical records revealed an Elopement Evaluation with a start date of August 11, 2023, at 9:30 a.m. The Elopement Evaluation for Resident R12 was completed and signed during the abbreviated complaint survey on August 21, 2023, at 11:40 a.m. A review of facility nursing assignments dated August 10, 2023, through August 11, 2023, for all three shifts revealed that Nurse Assistant, Employees 15, 16, 17, and 21 were assigned to Resident R12 and provided direct care. Continued review of the Facility Investigation Report failed to reveal written statements from nurse aides who provided direct care to Resident R12 on August 10 and August 11, 2023. During the exit meeting conducted on August 22, 2023 at approximately 4:40 p.m. the Nursign Home, Administrator, Director of Nursing, and Assistant Director of Nursing confirmed the above-mentioned findings. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(d)(1) Nursing services 395481 Page 8 of 8