Health inspection·March 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three of 19 sampled residents in one of two dining areas. (Second Floor) (Residents 18, 27, 54) Findings include: Clinical record review revealed that Resident 18 had diagnoses that included Alzheimer's disease and dysphagia, oral phase (difficulty chewing before swallowing). Review of the Minimum Data Set (MDS) assessment, dated February 27, 2025, revealed that the resident had cognitive impairment and needed assistance from staff with eating. Review of Resident 18's care plan revealed that staff was to provide total assistance with feeding. Resident 27 had diagnoses that include Alzheimer's disease and dysphagia, oropharyngeal phase (difficulty swallowing). Review of the MDS dated [DATE], revealed that the resident had cognitive impairment and needed staff assistance with eating. Review of Resident 27's care plan revealed that staff was to provide total assistance with feeding. Resident 54 had diagnoses that include frontotemporal neurocognitive disorder. Review of the MDS dated [DATE], revealed that the resident had cognitive impairment and needed assistance from staff with eating. Review of Resident 54's care plan revealed that staff was to provide total assistance with feeding. On March 25, 2025, from 12:45 p.m. through 1:05 p.m., nurse aide (NA) 1 was observed standing while assisting Residents 18, 27, and 54 with lunch. On March 25, 2025, from 12:37 p.m. through 12:45 p.m., NA 2 was observed standing while assisting Resident 27 with lunch. In an interview on March 27, 2025, at 10:04 a.m., the Administrator stated that staff were not to stand over residents while feeding them. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 3 395507 395507 03/27/2025 Elm Terrace Gardens 660 North Broad Street Lansdale, PA 19446

F 0641 Ensure each resident receives an accurate assessment. 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 staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed accurately to reflect the current status of one of 19 sampled residents. (Resident 8) Residents Affected - Few Findings include: Clinical record review revealed that Resident 8 was admitted to the facility on [DATE]. Review of an admission nursing assessment, dated March 1, 2025, revealed a lack of evidence that the resident had a pressure ulcer upon admission. In an interview on March 26, 2025, at 11:10 a.m., Registered Nurse 1 stated that the resident did not have any pressure ulcers during his admission to the facility. Review of section M of the MDS assessment, which assessed skin conditions, dated March 7, 2025, indicated that the resident had a stage two pressure ulcer that was present upon admission. There was a lack of evidence to indicate that the resident had a stage two pressure ulcer while in the facility. In an interview on March 27, 2025, at 9:46 a.m., the Director of Nursing confirmed that the MDS assessment was not accurate. 395507 Page 2 of 3 395507 03/27/2025 Elm Terrace Gardens 660 North Broad Street Lansdale, PA 19446

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on policy review, observation, and staff interview, it was determined that the facility failed to serve food in a sanitary manner in one of two dining areas (Second Floor). Residents Affected - Few Findings include: Review of the facility's policy, Hand Washing/Hand Hygiene, dated January 7, 2025, revealed staff was expected to wash their hands and wear disposable gloves that are replaced between tasks during which they may have been soiled. On March 25, 2025, from 12:50 p.m. to 1:25 p.m. Dietary Aide 1 was observed wearing one pair of gloves to assist resident 27 with utensils, clear soiled plates, and assist with preparing plates of food for other residents. At no time did Dietary Aide 1 change gloves between tasks. In an interview on March 27, 2025, at 10:04 a.m., the Administrator stated that staff completing dining tasks were to change disposable gloves between tasks. 28 Pa. Code 201.14(a) Responsibility of licensee. 395507 Page 3 of 3