Health inspection·September 25, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and staff interview, it was determined that the facility failed to ensure that notices of Medicare non-coverage Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) were provided timely for two out of three residents reviewed (Residents R273 and R158) Residents Affected - Few Findings include: The SNF ABN provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with the SNFABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related standard claim appeal rights. Review of Residents R273's Medicare non-coverage information indicated that Resident R273 was to receive a SNFABN. Facility documentation indicated that Resident R273 had last covered date of Part A service end on March 23, 2023. There was no evidence that Resident R47 received SNFABN. Review of Residents R158's Medicare non-coverage information indicated that Resident R158 was to receive a SNFABN. Facility documentation indicated that Resident R158 had last covered date of Part A service end on May 3, 2023. There was no evidence that Resident R158 received SNFABN. Interview with facility's admission representative, Employee E20 on September 21, 2023 at 1:20 p.m. revealed no evidence of knowledge of required notifications to be provided for residents who choose to remain in facility. F 28 Pa. Code 201.18(e)(1)Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 2 of 11 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 395481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Center 1245 Church Road Wyncote, PA 19095 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment for one of three nursing units observed. (Unit one). Residents Affected - Few Findings Include: Observation made of the first floor balcony/patio area on September 22, 2023 at 9:17 a.m. from the inside of the building from the second floor. There appeared to be a medication cart, geri-chairs, and spare wheelchairs outside being stored on the patio area. Interview and observation made with Director of Maintenance, Employee E10 on September 22, 2023 at 9:19a.m. revealed the equipment that was currently on the patio area was all transferred outside from the facility tub rooms. When asked when the items were moved outside the Director of Maintenance, Employee E10 stated Wednesday the items were moved. When questioned why the items were moved outside the Director of Maintenance, Employee E10 stated, they were needing to get things out of the tub rooms, and with you all coming here on Wednesday it pushed them a little bit. Observation was made on September 22, 2023 at 9:20 a.m. and there was trash on the porch area. There was a large trash can with standing water full to the top with a spare trash bag, some empty wrappers, and empty bottles floating on top of the trash can full of water. On the patio area there was spare equipment, and broken equipment being stored. This area is located outside of the first floor dining area. On the patio area next to the facility there were six wheel chairs, two high back wheelchairs, six geriatric chairs, two laundry carts, one medication cart, and a dining room table. Further observation of the outside patio and porch area was made on September 25, 2023 at 10:14 a.m. The porch area contained six geriatric chairs and a dining room table. The patio area still had a large trash can with standing water full to the top with a spare trash bag, some empty wrappers, and empty bottles floating on top of the trash can full of water. 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 3 of 11 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 395481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Center 1245 Church Road Wyncote, PA 19095 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and observations , it was determined that the facility did not provide appropriate care for activities of daily living (ADL), including incontinence care and oral hygiene care for two out of 35 residents reviewed (Resident R115 and R134). Residents Affected - Few Findings include Observations of Resident R115 on September 20, 2023 at 11:00 a.m, revealed resident laying in bed with significant oral odor noted, and complaining of staff not assisting him of mouth care during morning hygiene. Finding confirmed with nurse aide, employee E21. Review of R115's clinical records revealed diagnosis of nontraumatic subdural hemorrhage, spastic hemiplegia (type of cerebral palsy where muscle stiffness affects one side of body), muscle weakness, contracture of left hand, wrist and elbow. According to R115's care plan, resident requires assistance/ is dependent for activities of daily living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: functional decline. Additional review of Residents R115' Minimum Data Set (MDS) dated [DATE], revealed that Resident R115 required extensive assistance with two or more persons physical assistance for personal hygiene. Observation of Resident R134, on September 20, 2023 at 10:40 a.m. on unit one, First floor, revealed Resident R134 laying in bed with significant urine odor noted; finding confirmed with licensed nurse, Employee E18. Per nursing report, Resident R134 was incontinent and required assistance with changing briefs. Review of Resident R134's MDS dated [DATE], revealed that Resident R134 required supervision/oversight, encouragement or cueing as well as one person physical assistance for toilet use. Review of Resident R134's care plan revealed that resident is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: illness, fall, hospitalization, etc. resulting in fatigue, activity intolerance, confusion. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5)Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 4 of 11 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 395481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Center 1245 Church Road Wyncote, PA 19095 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observations of residents and activities programing, review of activities calendar, interview with staff and residents, it was determined that the facility failed to employ sufficient support staff to provide recreational programs to meet the psychosocial, emotional, and care needs on three of three nursing units. Residents Affected - Some (First, Second and Third floor) Findings include: Review of facility policy titled Recreation Services Policies and procedures revised April 7, 2018 states that residents have the right to participate or not participate in leisure and recreation of their choosing. Further evaluation of this policy revealed that residents will be invited to attend activities of preference and interest and will be provided the opportunity to participate in a structured and individual programs. Observation on September 20, 2023 at 11:25 a.m. on the First-floor activities room there were 13 residents observed sitting at tables with an employee at the door to monitor. There were no activities taking place at this time. Review of the weekly scheduled provided stated that there was bingo scheduled at 2:00 p.m. on September 21, 2023. Observation on September 21, 2023 at 2:05 p.m. on the First-floor activities room included nine residents, Second floor activities room included 4 residents and there were no residents present in the Third floor activity room. Neither floors had any activities. Observation on September 22, 2023 on the Second-floor activities room revealed there was no resident in the room, there was no activities happening. Per the activity schedule the resident were to be engaged in the activity Manicures. Interview with Resident R124 revealed that there are not any activities of interest. Interview with Activities director Employee E9, on September 20, 2023 at 1:40 p.m. a request was made for the activities calendar. Employee E9 stated that there is shortage of staffing in the activities department, consequently there was not a complete monthly calendar. Employee E9 provided weekly activities that consisted of an activity for one floor at 2:00 p.m. daily. Employee E9 stated that there are no activities on weekends due to staff shortage. Tour of the facility revealed no activities observed any time. Interview conducted with Activities Director, Employee E9 on September 25, 2023 revealed that there were no activities on the previous day of observation due to field trip to a local department store for only a few residents. Employee E9 admits to not having activities for all resident, stating that the residents can always ask for a coloring book. 28 Pa Code 2012.18 (b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 5 of 11 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 395481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Center 1245 Church Road Wyncote, PA 19095 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, resident clinical record and staff interview, it was determined that the facility failed to ensure that physician's orders were followed related to an abdominal binder to secure a feeding tube for one of one resident review receiving eternal feeding. (Resident R54) Findings include: Review of Resident R54's September 2013 physician orders revealed an order for abdominal binder to be off of resident during skin assessments. Further review of physician orders revealed that skin assessments were to be conducted once a shift. Observations of Resident R54 on September 20, 2023 at 10:30 a.m., revealed that the resident was laying in bed with enteral tube feeding line disconnected and nutrition spilled on to bed linens and two puddles of nutrition spilled on floor near residents bed. Resident's abdominal binder was off of resident and placed at foot of bed. Surveyor brought up to the attention of Licensed nurse, Employee E18 on September 20, 2023 at 10:35 a.m. the observations made of Resident R54's as stated above. Licensed nurse, Employee E18 stated that the nurse aide and housekeeping were aware and they were going to take care ot it. The facility failed to ensure that an abdominal binder was placed on Resident R54 to secure the tube feeding as order by the physician. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 6 of 11 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 395481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Center 1245 Church Road Wyncote, PA 19095 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 observation, review of facility policy and interviews with staff, it was determined that the facility failed to provide food and drink that was palatable, attractive, and served at appetizing temperatures on two of three nursing units. (First Floor and Second Floor) Residents Affected - Few Findings Include: Review of facility policy titled Time and temperature control and recording. The purpose of the policy states, To educate all new hires and current employees on the importance of and guidelines for time and temperature control and recording procedures. Bacteria and other foodborne pathogens can grow quickly in the temperature Danger Zone of 41-135 degrees Fahrenheit. Proper thawing, cooking, reheating, holding, and transport of food is critical for resident safety and wellness. Observation was made on September 22, 2023 at 11:46a.m. of food trays being prepared in the kitchen. On September 22, 2023 at 12:14 p.m. the box cart holding the test tray left the kitchen to go to the Third floor. At 12:16 p.m. it arrived on the Third floor. At 12:27 p.m. all other food trays were passed out on the floor. At 12:28 p.m. the food tray was taken out of the box cart. The temperatures were tested for both the cold and the hot foods. The temperature of the fish at 12:29 p.m. was 132.5 degrees Fahrenheit. The milk temperature was 51.4 degrees Fahrenheit. On September 25, 2023 at 12:05 p.m. the box cart holding the test tray left the kitchen to go to the first floor. At 12:07 p.m. it arrived on the first floor. At 12:18 p.m. the food tray was taken out of the box cart. The temperature of the egg salad served was 52 degrees Fahrenheit. The temperature of the beet salad served was 53 degrees Fahrenheit. 28 Pa. Code 210.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 7 of 11 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 395481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Center 1245 Church Road Wyncote, PA 19095 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for two of three nursing units. (First floor and Second floor). Residents Affected - Few Findings Include: Review of Facility Policy: Food: Safe Handling for Foods from Visitors revised 7/2019 states Resident will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. The procedure states, 5. Refrigerator/Freezers for storage of foods brought in by visitors will be properly maintained and: Equipped with thermometers. Have temperature monitored daily for refrigeration less than or equal to 41 degrees Fahrenheit and freezer less than or equal to 0 degrees Fahrenheit. Daily monitoring for refrigerated storage duration and discard any food items that have been stored for seven days or more. (Storage of frozen foods and shelf stable items may be retained for 30 days.) Cleaned weekly. Observation of the nourishment closet on the Second floor was made on September 20, 2023 at 11:33 a.m. in the resident refrigerator there was a bag of takeout food for Resident R83 labeled September 10, 2023. There was a bag of takeout French fries undated and with no resident name. There was a container of prune juice that was on it's side and spilled all over the inside of the door refrigerator. There was a small opened container of orange juice undated with no resident's name. Confirmation on the condition of the resident refrigerator was made by Licensed nurse, Employee E5 on September 20, 2023 at 12:13 p.m. Review of the Second floor resident refrigerator's temperature log revealed that there were no documentation of the temperatures of the refrigerator on September 3, 4, 10, 16, 17, 18, and 19. Observation on September 20, 2023 at 12:27 p.m. of the First floor's nourishment closet revealed a resident refrigerator with no temperature log. In the refrigerator was takeout food in blue bag no label. A yogurt was in a bag in freezer with no label. Interview on September 20, 2023 at 12:32 p.m. with Director of Maintenance, Employee E10 revealed that the inside of the refrigerators would be maintained by housekeeping. 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 8 of 11 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 395481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Center 1245 Church Road Wyncote, PA 19095 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of facility's documentations and interview with staff, it was determined that the facility did not take actions aimed at performance improvement and after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. Findings include: Review of facility's Quality Assurance Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) agenda for July 19, 2023, revealed areas of concern regarding food delivery system, room furniture/old appearance, medications in med carts (old), re-hospitalization rate, agency usage. Further review of agenda revealed 'action steps' to be taken with 'on-going' follow-up. Facility was not able to provide evidence for measuring success of suggested action plans for the areas noted above. Facility was not able to show documented evidence of tracking performance. Review of facility's QAPI and QAA agenda for August 16, 2023, revealed areas of concern regarding food delivery system, re-hospitalizations, and recruitment/retention. Further review of agenda revealed 'action steps' to be taken with 'on-going' follow-up. Facility was not able to provide evidence for measuring success of suggested action plans for the areas noted above. Facility was not able to show documented evidence of tracking performance. Review of facility's assessment plan dated September 9, 2022 through September 8, 2023 revealed that B.1 Acuity - QAPI Action/Plan Summary: facility goes through all assessments on an annual basis. Any area identified as lacking will be addressed in QAPI with root cause analysis and reported on until issue is rectified. Further review of facility's assessment revealed number of admissions/stays ending in hospitalization as 'high', stays ending in death as 'high', malnutrition - 'very high', swallowing difficulty - 'very high', feeding tube - 'high.' Review of QAPI meeting minutes for months of May 17, 2023, July 19, 2023 and August 16, 2023, revealed no evidence of facility addressing areas of concern mentioned above based on facility's assessment. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 9 of 11 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 395481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Center 1245 Church Road Wyncote, PA 19095 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility's documentation, and staff interview, it was determined that the facility did not hold Quality Assurance Process Improvement meetings at least quarterly for one out of four quarters reviewed (first quarter, January - March 2023) Residents Affected - Some Findings include: According to facility's framework for Quality Assurance/ Performance Improvement, committee must be comprised of director of nursing (DON), infection preventionist, medical director or designee and 3 additional team members one of which is the administrator. A consultant pharmacist is recommended to serve on the committee. This is a minimum requirement. CMS SOM states other department heads should have the opportunity to be involved as well as residents and family having vital information for the committee. The Quality Assessment and Assurance (QAA) committee will meet ten times a year. QAA activities and outcomes will be on the agenda of every staff meeting and shared with residents and family members. Centers will define process for communication with residents and family members. The QAA committee will have responsibility for reviewing data, suggestions, and input from residents, staff, family members, and other stakeholders. The QAA committee will prioritize opportunities for improvement and determine which performance improvement projects will be initiated. When an issue or problem is identified that is not systemic and does not require a performance improvement project During interview with Nursing Home Administrator on September 25, 2023, it was confirmed that facility was unable to provide QAPI meeting minutes for months of January 2023 through March 2023. Review of 'Hillcrest Center Quality Assurance and Improvement Meeting' dated May 17, 2023, revealed no pharmacy consultant present during meeting. 28 Pa Code 201.18(e)(1)(2)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 10 of 11 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 395481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Center 1245 Church Road Wyncote, PA 19095 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 Based on observation and review of policy and procedure, it was determined that the facility failed to maintain an effective infection control program related to the appropriate cleaning of medical equipment on one of three nursing units. (Second floor) Residents Affected - Few Findings include: Review of facility policy titled Infection Control Policies and Procedures - IC201 Cleaning and Disinfecting revised May 1, 2023, states that noncritical items are objects that do not come into contact with mucus membrane but do come into contact with intact skin (e.g., blood pressure cuff, glucose meters, stethoscope, activity supplies, sensory manipulatives, craft supplies). These items require cleaning between patient use. Observations conducted during medication pass on September 20, 2023 at 9:27 a.m. with Licensed nurse Employee E15, revealed that the Dinamap (an instrument used to monitor vital signs including blood pressure, pulse rate, oxygen, and temperature ), was utilized between Resident R117 and Resident R143 without being disinfected between residents. Observation conducted during medication pass on September 20, 2023 at 10:29 a.m. with Licensed nurse Employee E14 revealed the Dinamap was utilized on Resident R228 without being disinfected. Observation of Licenced Nurse, Employee E5 on September 21, 2023 at 9:37 a.m. on the Second floor back hall, utilizing the Dinamap without disinfecting it before or after usage between residents. 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395481 If continuation sheet Page 11 of 11