Health inspection·August 9, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 environmental observations of two of thirty-six resident rooms, reviews of policies and procedures, interviews with staff and residents, it was determined that the facility failed to ensure reasonable care for the protection of resident's property from loss or theft for two of 22 residents reviewed. (Resident R88 and Resident R27) Findings include: Review of the policy titled Abuse: zero tolerance dated February 25, 2009 revealed that it was the responsibility of the administrator to create an atmosphere at the facility in which abuse of any nature toward or by a resident, co-worker, visitor or service provider was not acceptable behavior. The policy indicated that the definition of abuse included but was not limited too misappropriation of property. Misappropriation of property was the deliberate misplacement, exploitation, or wrongful (temporary or permanaent) use of a resident's belongings or funds without the resident's consent. The policy also indicated that the facility was responsible for investigation to determine the causative factor of the missing personal property. The facility was also responsible for listing the amount of money missing, staff who would have had access to the money, when the money was last seen and where the money was usually kept. Review of the policy titled room furnishings dated August 8, 2024 revealed that the facility was responsible for providing each resident with a drawer or cabinet in their room that could be locked. Clinical record review for Resident R88 revealed a quarterly assessment MDS (an assessment of care needs) dated May 2, 2024 that indicated that this resident was cognitively intact. The assessment also indicated that Resident R88 had no functional limitations in range of motion of the upper extremities. Review of information reported to the State Survey agency dated May 16, 2027 indicated that Resident R27 reported to staff that she was missing money from her wallet. A total of $110.00 was missing on May 16, 2024, after she returned to the facility from the dialysis center. Interview with Resident R27 at 10:00 a.m., on August 9, 2024 confirmed that money in an amount of $110.00 dollars was never returned to her. Further interview with Resident R27 revealed that she was not offered or provided with a drawer or cabinet inside her room that could be locked to secure her personal property. Observations of Resident R27's bedroom revealed that this resident did not have a drawer or cabinet that could be secured for storing personal belongings. Page 1 of 11 395715 395715 08/09/2024 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Social Worker, Employee E12 at 10:30 a.m., on August 8, 2024 confirmed that Resident R27 was not offered or provided furniture in her room that could be locked or secured to safeguard personal property (money). Review of a report submitted to the State Survey Agency dated June 16, 2024 indicated that Resident R88 reported to staff that he was missing money from his desk drawer inside his room. Resident R88 reported that a total of $30.00 dollars had been removed from his desk. Observations of resident R88's bedroom revealed a piece of furniture that he brought into the facility from home. This desk was not able to be locked. There was no furniture provided by the facility inside the resident's room that had a locking drawer or cabinet to secure personal belongings (money). Interview with resident R88 at 9:30 a.m., on August 9, 2024 revealed that the resident was never offered a drawer or cabinet inside his room to safeguard his belongings. Interview with the Social Worker, Employee E7, at 11:00 a.m., on August 9, 2024 confirmed that Resident R88 had not been offered or provided a locked drawer or cabinet in his room to secure his personal belongings. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 201.29(a)(b)(c) Resident rights 28 PA. Code 205.72 Furniture 395715 Page 2 of 11 395715 08/09/2024 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. Based on observation, clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive person-centered care plan related to edema for one of 22 resident records reviewed (Resident R42). Findings include: Review of Resident R42 quarterly MDS (Minimum Data Set, an assessment of residents' needs) dated May 14, 2024, assessed the resident with severe, cognitive impairment, physical impairments to one side of the resident's upper and lower body, dependent on staff for wheelchair mobility, toileting, personal hygiene, and bathing. The MDS contained diagnosis of high blood pressure, Peripheral vascular disease (restricted blood flow to the lower extremities) Diabetes Mellitus (lack of insulin needed to send glucose to cells, leading to high blood sugar) Cerebrovascular Accident (stroke) and clinically depressed. Review of Resident R42's nursing progress notes noted the resident's right hand first appeared swollen on January 20, 2024. Physician orders dated March 9, 2024, instructed to elevate the resident's right upper extremity at all times for edema (swelling cause by ex excessive fluid accumulation). On August 5, 2024, at approximately 12:00 p.m. it was observed with Licensed Practical Nurse (LPN) Employee E13 that Resident R42 was in bed with her right arm by her side not elevated. The LPN confirmed orders to elevate the resident's right arm due to edema. Further review of Resident R42's clinical record revealed the facility failed to develop a plan of care for the resident's edema including intervention that included elevating the extremity . 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing service 395715 Page 3 of 11 395715 08/09/2024 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and interviews with staff, it was determined that the facility failed to ensure a neurological assessments were completed and to obtain orders for the use of a hand splint for two of 22 residents records reviewed (Resident R85 and Resident R42). Residents Affected - Few Findings include Review of Resident R85's quarterly MDS (an assessment of residents' needs) dated June 24, 2024, was assessed as severely, cognitively impaired with unwanted physical and verbal behaviors to others The same MDS indicated the resident required supervision from staff for walking, using a cane or walker for ambulating. Review of Resident R85's care plan revealed he was a high risk for falls due to his impaired cognition and at risk for bleeding due to his diagnosis of Atrial fibrillation (irregular heartbeat with increased risk of blood clots and stroke). The resident was ordered Eliquis, an anticoagulant (blood thinner) medication used to decrease the risk of stroke. Care plan interventions included to monitor for bruising and or bleeding, and any decline in function and to notify the physician as needed. Interview with the facility's Medical Director on August 8, 2024, explained there is an increased risk of bleeding when you are on an anticoagulant. Not every fall or an unwitnessed fall (potential head injury) immediately needs to go to the hospital. Nurses are instructed to perform Neurological assessments that start immediately after the fall occurs. This is done numerous times in the first 24 hours and if neurological changes are seen, they would contact the doctor for further instructions. Further review of Resident R85's clinical record revealed on the following dates July 21, April 30, 29, and February 4, 2024, the resident experienced Unwitnessed falls and no evidence of the neurological assessments were completed by nursing. On August 8, 2024, at 1:00 p.m. the Director of Nursing and the Nursing Home Administrator were requested neurological assessments for the above dates, and revealed no further documented evidence the assessments were completed. Review of Resident R42's quarterly MDS (Minimum Data Set, an assessment of residents' needs) dated May 14, 2024, assessed the resident with severe cognitive impairment, physical impairments to one side of the resident's upper and lower body, dependent on staff for wheelchair mobility, toileting, personal hygiene, and bathing. The same MDS indicated the resident was diagnosed with high blood pressure, Peripheral vascular disease (restricted blood flow to the lower extremities) Diabetes Mellitus (lack of insulin needed to send glucose to cells, leading to high blood sugar) Cerebrovascular Accident (stroke) and clinically depressed. On August 5, 2024, at 12:00 p.m., it was observed with Licensed Practical Nurse (LPN) Employee E13, Resident R42 had a splint on her left hand. Review of Resident R42's physician order revealed the order for the resident's splint was discontinued and no evidence of an active order was found. On August 7, 2024, at 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to 395715 Page 4 of 11 395715 08/09/2024 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0684 obtain an order for Resident R42's splint and no evidence the skin was being assessed while in use. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing service Residents Affected - Few 395715 Page 5 of 11 395715 08/09/2024 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility documentation and interviews with staff, it was determined that the facility did not ensure that each resident received adequate supervision to prevent a resident from falling out of the bed during personal care for one of 22 records reviewed (Resident R38). Findings include: Review of Facility Policy, Turning A Resident on His/Her Side Away From You undated, Purpose: The purposes of this procedure are to provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment. Preparation: Review the resident's care plan to assess for any special needs of the resident. Review of Resident R38's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side Muscle weakness or partial paralysis can't get rid off on one side of the body that can affect the arms, legs, and facial muscles); dysphagia (difficulty swallowing); muscle weakness and morbid obesity; Review of the quarterly Minimum Data Set- (a periodic review of residents needs) dated May 13, 2024, indicated that the resident was cognitively impaired and is rarely understood. Further review revealed that the resident was dependent (helper does all of the effort) for rolling left and right (the ability to roll from lying on back to left and right.) Functional status for bed mobility indicates extensive assistance with two persons physical assist. Review of Resident R38's plan of care dated March 16, 2024 revealed: I have an ADL (activity of daily living) deficit due to CVA (cerebral vascular disease) with right sided hemiplegia. I will be kept clean with dignity maintained. Staff will assist X 2 (staff member) when providing care. Review of nurse progress note dated May 20, 2024 revealed Nurse aide, Employee 21, Resident fell from bed. Small amount of blood around mouth was wiped away. Resident complained of pain in the face and right leg. Resident was assisted back to bed via hoyer. Resident was assessed. NP (Nurse practitioner) and family notified. Physician and NP in agreement to administer tylenol and begin neuro-checks (a neurological exam is a series of tests and questions that assess a person's nervous system, including the brain, spinal cord and nerve function). Continued review revealed .that Resident R38 will receive a bariatric bed. Review of facility documentation, Fall Investigation revealed Employee E20, nurse aide, note: I turned her on her left side and she went straight on the floor. Resident did not hit her head. She was face down lying on the floor. Interview on August 6, 2024 at 10:00 am. with Employee E2, Director of Nursing revealed, That staff member is no longer employed here. Employee was terminated. Interview on August 6, 2024 at 10:30 a.m. with Employee E18, Second Floor Unit Manager, revealed I conducted a re-education with our staff. We placed this resident on paired care. Residents who are 395715 Page 6 of 11 395715 08/09/2024 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0689 on paired care will be placed on resident's dashboard. Level of Harm - Minimal harm or potential for actual harm The facility failed to ensure that Resident R38 was provided with two persons physical assist during personal care. Residents Affected - Few 28 Pa. 28 Code 201.14 (c) Responsibility of Licensee 28 Pa. 28 Code 201.18(b)(1) Management 28 Pa. 28 Code 211.12 (d)(1)(5) Nursing Services 395715 Page 7 of 11 395715 08/09/2024 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, interviews with resident and staff, and facility policy. it was determined that the facility failed to obtain services in a timely manner when the facility could not obtain these services on site to meet the needs of one of 22 resident records reviewed (Resident R62). Residents Affected - Few Findings included: Review of facility policy and protocol for labs and diagnostic test results reviewed in November 2018, revealed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Review of Resident R62's Admission's MDS (an assessment of residents' needs) dated May 16, 2024 assessed the resident as alert and oriented, independent of making daily life decisions diagnosed with a fracture, coronary heart disease, high blood pressure, diabetes mellitus (lack of insulin needed to send glucose to cells, leading to high blood sugar), cerebral vascular accident (stroke) with one sided weakness, one unstageable pressure ulcer due to a device found on admission, Interview with Resident R62 on August 6, 2024 at 2:12 p.m. indicated at home she fell and broke her ankle in two places. The resident stated, I didn't know it but when I fell I had a heart attack. While I was in the hospital from the fall, I had a stroke. I wear an immobilizer (for healing of fracture) I got a wound on the inside of my left ankle and was seeing a wound doctor at the hospital. Review of Resident R62's physician's wound notes dated June 11, 2024 revealed the physician ordered ankle-brachial pressure indices (ABIs) a diagnostics for lower extremity arterial disease), left arterial duplex ultrasound (examines the arteries that carries blood to the leg) and left venous reflux ultrasound (evaluate for venous insufficiency). When Resident R62 returned from the appointment, nursing progress note, dated June 11, 2024, noted the three tests prescribed by the physician and that the doctor was Made aware of the recommendations and approved. Review of the following wound appointment dated June 25, 2025, indicated on the last visit (June 11, 2024) prescription for ABI's, left arterial duplex ultrasound, and left venous reflux ultrasound sent with patient to take to facility in order for the facility to schedule. The studies need to be done prior to follow-up in two weeks. Further review of Resident R62's clinical records revealed no evidence the ABI test was conducted. Interview with Unit Manager Employee E11 on August 8, 2024, at 1:00 p.m. stated we don't do ABI at the facility, and I do not see the test completed. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395715 Page 8 of 11 395715 08/09/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on environmental observations of the food and nutrition department, interviews with staff and reviews of policies and procedures, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Review of the undated dietary policy titled cleaning of the main kitchen revealed that it was the responsibility of the dietary employees to ensure that food service equipment, housekeeping of the physical environment of the kitchen was cleaned and sanitized routinely. The dietary staff were responsible to report any maintenance issues to the maintenance department for repairs of equipment and structural adjustments. An environmental tour of the main kitchen where foods and beverages were being prepared, stored and distributed to the satellite kitchenettes on the firsrt floor and second floor nursing units revealed the following: The main kitchen environmental tour was completed with the director of dietary services, Employee E5 10:00 a.m., on August 5, 2024 and 9:30 a.m., on August 6, 2024. Interview with the director of dietary, Employee E5, at 10:30 a.m., on August 6, 2024 confirmed the lack of routine implementation of proper sanitation and food handling to prevent foodborne illness. Observations of the three compartment sink area where racks of cleaned dishes were being stored for cooking and food preparation revealed light fixtures and ceiling tiles that were heavily soiled with dust, dirt and food debris. A majority of the ceiling tiles contained brown stained and water damage. The area was dim and missing overhead lighting. The light screenscontained a collection of dead common household pests (roaches). The fan blowing directly on cleaned pots, pans, trays and dishes was heavily soiled with dirt and dust. The ceiling vent in this area was heavily soiled with dust and dirt. The wall area surrounding the three compartment sink was soiled with dried food debris. The sink garbage disposal for food scraps and kitchen waste was consistenly running spewing water into the sink and sorting area for cleaned dishes. There was no lid/cover for the garbage disposal while in use. The floor area underneath the three compartment sink, garbage disposal and large racks of cleaned dishes was covered with water. The floor drains contained a build-up of food debris and dirt which was obstructing the floor of water into the drain. The metal door leading directly outside the facility to the trash and refuse area was was not sealing completely. The threshold of the door upon closing left a one inch air gap and easy access to the building for common household pests and rodents. The dry food stage area was located adjacent to the unsealed doors. The entrance to the main kitchen of the food and nutrition department was located near the improperly installed doorway. 28 PA. Code 201.14(a) Responsibility of licensee 395715 Page 9 of 11 395715 08/09/2024 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0812 28 PA. Code 201.18(b)(1)(2.1) Management Level of Harm - Minimal harm or potential for actual harm 28 PA. Code 211.6(f) Dietary services Residents Affected - Some 395715 Page 10 of 11 395715 08/09/2024 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to maintain proper infection control practices to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of 22 residents reviewed (Resident R8 and R42 ) Residents Affected - Few Findings include: Infection control policy for all nursing care procedures when caring for residents, revised on August 2012 states to perform hand hygiene after removing gloves, before handling clean or soiled dressings, and before moving from a contaminated body site to a clean body site during resident care and to perform hand hygiene before preparing or handling medications. Review of the facility policy Enhanced Barrier Precautions Policy and Procedure updated August 2024, states the purpose of this policy is to mitigate the risk of transmission of Multidrug-Resistant Organisms (MDRO) by implementing Enhanced Barrier Precautions (EBP) by expanding the use of personal protective equipment (PPE) during high-contact resident care activities for certain residents. High contact examples include, providing hygiene, changing briefs, or assisting with toileting, device care or use of feeding tube and wound care. The same policy further states that indwelling medical device, is a device that provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices for which EBP should be used include, but are not limited to indwelling urinary catheters and Feeding tube. Review of Resident R42 quarterly MDS (Minimum Data Set, an assessment of residents' needs) dated May 14, 2024, assessed the resident with severe cognitive impairment, physical impairments to one side of the resident's upper and lower body, dependent on staff for wheelchair mobility, toileting, personal hygiene and bathing. The MDS included diagnosis of high blood pressure, Peripheral vascular disease (restricted blood flow to the lower extremities) Diabetes Mellitus (lack of insulin needed to send glucose to cells, leading to high blood sugar) Cerebrovascular Accident (stroke) and clinically depressed. Review of Resident R42 physician orders effective since March 9, 2024, revealed the resident required a G-Tube (a surgically inserted feeding tube into the stomach for nourishment), instructed to wash the site daily with soap and water, to apply a foam dressing pad daily to the sacrum for preventative care. On August 5, 2024 at 12:15 p.m with Licensed Practical Nurse (LPN) Employee E13 and Nursing Assistants (NA) Employee E16 and E17, Resident R42's incontinence and wound care was observed and staff did not ensure the enhanced barrier protection was being followed. During wound care the LPN removed Resident R42's sacral dressing and failed to clean hands prior to donning new gloves. August 7, 2024 at approximately 9:00 a.m. during medication administration LPN E13 held Resident R8's cup with hand on top of cup and palm rested on the rim as the drink was delivered to the resident. 28 Pa. Code 211.12(c )(d)(5) Nursing services 395715 Page 11 of 11