Health inspection·September 28, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interviews with resident and staff, it was determined that the facility failed to maintain dignity and respect while providing care for one of 29 clinical records reviewed (Resident R80). Residents Affected - Few Finding includes: Review of Resident R80 quarterly MDS (Minimum Data Set- an assessment of resident's needs) dated July 11, 2023, revealed the resident was cognitively intact and needed extensive assistants with dressing and hygiene. Interview with Resident R80 on September 26, 2023, at 12:40 p.m. stated, A nursing assistant was getting me ready while she was talking on the phone, talking about another staff member. She was getting mad on the phone, so she was rough when she was getting me ready. Review of facility documentation dated April 21, 2023, revealed Resident R80 was receiving care from a nursing assistant (NA), who was on the phone cursing. The resident stated because of of her anger and the way she was talking, her touch was not of care and compassion. Interview with the Nursing Home Administrator on September 28, 2023, at 3:30 p.m. confirmed the resident was not treated with dignity. 28 Pa. Code 201.29(d) Resident Rights Page 1 of 11 395715 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

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, review of clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet care needs for two of 29 residents reviewed. (Resident R88 and Resident R100) Findings include: Review of facility policy titled, Care Plans, Comprehensive Person- Centered, revised December 2016, indicated that the comprehensive care plan will describe services that would are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident R88's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated September 6, 2023, revealed Resident R88 was admitted to the facility on [DATE], with diagnoses including Dysphasia (impairment in the production of speech resulting from brain disease or damage), muscle weakness, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), and dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). Review of Resident's BIMS (Brief Interview for Mental Status) revealed resident had severely impaired cognition. Dining observations conducted on September 25, 2023, at 12:02 p.m. on the second-floor dining room, revealed, Resident R88 was served a chicken drumstick, which she could not eat. Further observations revealed the Resident had no upper teeth. Follow-up dining observations conducted on September 26, 2023, at 12:07 p.m. revealed Resident R88 could not eat the kielbasa that was served as part of her meal. Further observations revealed Nurse Aide, Employee E9, who was assisting the resident with her meal, requested a mashed potatoes and soup as an alternate meal. Interview conducted with Nurse aide, Employee E9 at approximately 12:10 p.m. Employee E9 stated, the outer skin makes it hard for her to chew and that Resident R88 had dentures but lost them about 3 months ago. Review of Resident R88's Oral/Dental Assessments dated September 30, 2020, and May 30, 2023, revealed, resident has full upper dentures and some teeth on lower. Further review of Resident R88's clinical record revealed no documented evidence a comprehensive care plan was developed regarding dentures and dental care. A review of Resident R100's MDS dated [DATE], revealed Resident R100 was admitted to the facility on [DATE], with diagnoses including brain dysfunction (brain damage), dementia, and muscle weakness. Review of Resident's BIMS revealed resident had mildly impaired cognition. Dining observations conducted on September 26, 2023, at 1:42 p.m. revealed resident did not eat the carrots and kielbasa served on her tray. Resident R100 stated, It is hard to chew because I don't 395715 Page 2 of 11 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0656 have upper teeth and requested soup as an alternate food. Level of Harm - Minimal harm or potential for actual harm Interview with Nurse Aide, Employee E11, revealed Resident R100 goes in and out of confusion; she must've put her dentures in the trash or left them on her tray. Residents Affected - Few Review of Resident R88's Oral/Dental Assessments dated October 8, 2021, and June 13, 2023, revealed that resident has full upper and lower dentures. Further review of Resident R100's clinical record revealed no documented evidence a comprehensive care plan was developed regarding dentures and dental care. An interview conducted on September 28, 2023, at 3:00 p.m. with the Nursing Home Administrator and the Director of Nursing confirmed the above-mentioned findings. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395715 Page 3 of 11 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

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, resident and staff interviews, it was determined that the facility failed to provide appropriate ADL care including incontinent care, and dressing for two of 29 residents reviewed (Resident R45 and R77) who was unable to carryout ADL care independently. Residents Affected - Few Findings include: Review of Resident R45's Quarterly MDS (Minimum Data Set-Assessment of resident care needs) dated September 7, 2023, revealed that the resident required extensive assistance from two staff for bed mobility, toileting and dressing, and was totally dependent on assistance from one staff for bathing. Review of the Annual MDS dated [DATE], revealed that the resident had a BIMS (Brief Interview for Mental status) score of 15 which indicated that the resident's cognitive status for daily decision making was intact. Interview with Resident R45 on September 25, 2023, at 11:05 a.m. stated he was still waiting for his aide to change his brief and get him cleaned up for the morning. The resident said that he had a loose bowel movement and had put his call bell on earlier, and the aide, Employee E4, came in and told him that she did not have time to change him before she had to be in the lounge to monitor the residents from 11:00 a.m. to 11:30 a.m. At 11:32 a.m. Resident R45 was still in his night gown and said that he had not been changed yet. Interview with Employee E4, nurse aide, on September 25, 2023, at 11:45 a.m. who was making the beds in room [ROOM NUMBER], stated that she was caring for the residents in rooms 126 to room [ROOM NUMBER], which included Resident R45 who was in room [ROOM NUMBER]. After she was finished making the beds in room [ROOM NUMBER], Employee E4 was observed at 11:50 a.m. gathering towels and a brief and going into room [ROOM NUMBER] and shutting the door behind her. Interview with Employee E7, Unit Manager on September 25, 2023, at 11:55 a.m., confirmed that Employee E4 was on duty monitoring the residents in the lounge from 11:00 a.m. to 11:30 a.m. Interview with the Nursing Home Administrator on September 28, 2023, at 2:05 p.m. acknowledged that Resident R45 had not received timely incontinent care on the morning of September 25, 2023, and that Resident R45 has had ongoing loose bowels, and if Employee E4 was not able to provide care she should have gone to someone for help. Review of Resident R77 admissions note dated April 13, 2023 revealed the resident was admitted to the facility on [DATE] diagnosed with status post left hip fracture with an intermedullary nail (a metal rod that is inserted into the fractured bone to provide support) with staples in place. The resident was oriented to herself able to verbalize her needs, diagnosed with Alzheimer's Disease (progressive disease causing a decline in thought memory and language), cardiac heart failure (the heart does not pump sufficiently) high blood pressure and chronic obstructive pulmonary disease (lung disease restricting air flow and breathing). Review of Resident R77's quarterly MDS (minimum data set of resident's needs) dated September 13, 2023, revealed the resident was incontinent of bowel and bladder and required extensive assistants with all activities of daily living including bed mobility, transfers, dressing, and hygiene. 395715 Page 4 of 11 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of the facility's grievance log revealed on April 22, 2023 a family member observed Resident R77 at 2:00 p.m. during a visit , not properly dressed and still in her nightgown. The resident's nursing assistant (NA) Employee E11 explained because she knew it would be painful for her to get dressed. On April 23, 2023, family observed Resident R77 not fully dressed and still in bed at 1130 a.m. The same NA stated she would not get Resident R77 out of bed unless the resident said it was okay. Residents Affected - Few Review of a witness statement from NA, Employee E11 stated Because of Resident 77's staples up and down her leg I was trying to prevent her from being in pain. I was considering my patients conformability level before transferring. This was confirmed with the Director of Nursing on September 28, 2023, at 3:00 p.m. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services 395715 Page 5 of 11 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations and staff interview, it was determined that the facility failed to post daily nurse staffing data on each nursing unit on September 28, 2023, on both nursing floors of the facility. Residents Affected - Few Finding include: Observations on September 28, 2023, at 2:15 p.m. on the first floor nursing unit at or near the bulletin board and nurse's station did not reveal that the staffing information was posted in a prominent place readily accessible to residents and visitors. Observations on September 28, 2023, at 2:20 p.m. on the second floor nursing unit at or near the bulletin board and nurse's station did not reveal that the staffing information was posted in a prominent place readily accessible to residents and visitors. An interview on September 28, 2023, at 2:20 p.m. with the Nursing Home Administrator, confirmed that the staffing information was not posted on the first or second floor. 28 Pa. Code 211.12 (d)(1)(3)(4) Nursing services 395715 Page 6 of 11 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

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 review of facility policy, observations, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Dish Machine Temperature Log, dated 2017, indicated that dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. Review of facility policy titled, Food Labeling Policy, indicated that all food items need to be labeled and rotated to ensure proper food safety . Each individual food item, when stored outside of its original box, will need to be tagged individually. Further review revealed, any item that is opened and being stored in its original manufacturer's container should be tagged with an orange Opened On label and the date it was opened is to be written legibly including the month, day, and year, in the following format MM/DD/YY. The Use First sticker should be used to indicate which item or product is the oldest to ensure proper food rotation. The blue Food Product Label (aka Prep Label) is to be used on any item that is stored outside of its original packaging, or on any prepped/prepared food item. Every line on the label needs to be clearly and legibly filled out. Review of undated facility policy titled, Cleaning Dishes/Dish Machine, indicated that prior to use, staff must verify proper temperatures and machine function. Further review revealed that a High Temperature Dish Machine must reach a wash temperature of 160 degrees Fahrenheit and a final rinse temperature of 180 degrees Fahrenheit. An initial tour of the Food Service Department conducted on September 25, 2023, at 9:43 a.m. with Employee E10, Food Service Manager, revealed the following: Observations in the manual dishwashing room revealed puddles of water. Dietary staff utilized this area to access clean pots and pans continually throughout the kitchen tour. Observations in in the dry storage room revealed the following items were opened, undated, and unlabeled: grits, cake mix, gelatin, pasta, and chocolate powder. Observations in the main walk- in refrigerator revealed the following items were unlabeled and undated: three pork rounds, corn beef brisket, six packages of ground beef, and two bags of chicken thighs. Further observations in the main cooking area revealed food and grease that have been burnt onto the inside of the oven and its windows. Dirt and grime were observed on the griddle. Observations in the kitchen maintenance area revealed brooms and mops were placed on the floor; the drain container was filled with filthy standing water and a damaged hose. Observations were confirmed by Employee E10, Food Service Manager, along the duration of the tour of the dietary department. 395715 Page 7 of 11 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0812 Level of Harm - Minimal harm or potential for actual harm Observations of the food service area on the second floor revealed steam table food temperatures were missing. Interview with the Dietary Team Lead, Employee E23, confirmed that she was running behind and did have a chance to validate safe internal temperatures of the food prior to serving residents; food temperatures at the steam table should have been verified and registered in the logbook prior to serving. Residents Affected - Many 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6 (f) Dietary Services 395715 Page 8 of 11 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to ensure a contract was in placefor continuity of dialysis services were available for one resident (Resident R52) who required dialysis services, for one of 32 records reviewed. Findings Include: Review of Resident R52's Quarterly Minimum Data Set (MDS, federally mandated resident assessment and care screening) dated September 10, 2023, revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Further review of the MDS revealed the resident had a diagnosis of end stage renal disease (when the kidneys permanently fail to work) and that he was receiving dialysis. Review of Resident R52's physician orders revealed a September 12, 2023, order for dialysis on Monday, Wednesday, Friday with a chair-time of 7:00 a.m. with a pick-up time of 6:00 a.m. Review of a facility documentation revealed that there was no contract in place for dialysis services for Resident R52. Interview on September 28, 2023, at 2:05 p.m. with the Nursing Home Administrator, confirmed that the facility had only one resident on dialysis, Resident R52, and that the facility did not have a contract in place with the dialysis center to ensure continued dialysis services for Resident R52. 28 Pa. Code: 201.21 (c) Use of Outside Resources 28 Pa Code:201.18(b)(1) Management 395715 Page 9 of 11 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations of the food and nutrition department, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition. Residents Affected - Few Findings Include: Review of undated facility policy titled, Cleaning Dishes/Dish Machine, indicated that prior to use, staff must verify proper temperatures and machine function. Further review revealed that a High Temperature Dish Machine must reach a wash temperature of 160 degrees Fahrenheit and a final rinse temperature of 180 degrees Fahrenheit. An initial tour of the main kitchen was conducted on September 25, 2023, at 9:43 a.m. with the Food Service Manager, Employee E10. Observations in of the dish machine revealed water was leaking from the pipe connection above the dish washer. When the dish machine was running, it was noted the pipe above the dish machine was leaking and the wash and rinse temperatures registered at 160 degrees Fahrenheit. Review of the dish machine temperature log revealed missing temperatures for September 12, 2023 through September 25, 2023, for breakfast, lunch, and dinner shifts. Review of documentation from the company who service the dish machine, dated September 25, 2023, revealed, booster heater was not getting proper electric because of blown fuse and that the water leak on pressure regulator and vacuum breaker needed to be replaced. Further review confirmed that the dish machine which was designed as a High Temperature dish machine was out of compliance. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(d) Dietary services 395715 Page 10 of 11 395715 09/28/2023 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program. Residents Affected - Some Findings include: Observations during a tour of the first floor of the facility on September 25, 2023, at 10:45 a.m. in room [ROOM NUMBER] revealed a fly buzzing around Resident R89 and landing on his bed and over-bed table. An interview on September 25, 2023, at 10:47 a.m., with Resident R89, who stated that the flies are a problem and that they constantly bother him. Observations during a tour of the first floor of the facility on September 25, 2023, at 10:50 a.m. in room [ROOM NUMBER] revealed several flies around a dirty brief that was sitting on the over-bed table. An interview on September 25, 2023, at 10:52 a.m., in room [ROOM NUMBER], with Resident R36, who stated that the flies are common in his room. Observations on March 8, 2023, at 11:05 a.m., in room [ROOM NUMBER] revealed small flies buzzing around the window. An interview on September 25, 2023, at 11:07 a.m., in room [ROOM NUMBER], with Resident R45, who stated that the flies are an ongoing concern in his room. A brief review of the pest logs at the facility revealed fly and gnat sightings. Reports from the pest control company confirmed observations and treatments for flies on several floors on several dates over the past few months. An interview on September 28, 2023, at 2:30 p.m. with the Administrator confirmed the pest logs sightings and pest company reports. 28 Pa. Code: 201.18(b)(1)(3) Management 395715 Page 11 of 11