Health inspection·May 8, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of facility policies, clinical records, and interviews with staff, it was determined that the facility failed to ensure that grievance regarding abuse/neglect was filed, tracked and promptly resolved for one of six residents reviewed. (Resident R1). Findings Include: Review of facility policy titled, Grievances/Complaints, Filing dated April 2017 states, 8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. 9. The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse, and/or misappropriation of property will be report and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law.10. The administrator will review the findings with grievance officer to determine what corrective actions, if any, need to be taken Review of the facility grievance log provided for the months on March, April and May 2025 revealed there was no grievance listed for the month of April 2025 for Resident R1. Interview conducted with Social Worker, Employee E7 on May 8, 2025 at 12:02 p.m. revealed that the Grievance Form was filled out because it was a reportable incident but it was not added to the Grievance Log. Employee E7 revealed she has been working at the facility for around two years. When asked about a facility Grievance Policy Employee E7 stated that she had no knowledge of a Grievance Policy since being employed at the facility. Facility Social Worker Employee E7 stated that she has the residents on the first floor but was currently filling in for the Social Worker who has the residents on the second floor. Employee E7 stated that Employee E9 has been out of Family Medical Leave since February 2025. When asked who was in charge of the Grievance Log Employee E7 stated herself and Employee E9. On May 8, 2025 at at 12:01 p.m. the Nursing Home Administrator Employee E1 was asked to provide a Grievance Policy. A Grievance Procedure was provided as a part of the facility admissions packet. The Nursing Home Administrator Employee E1 stated that he had no knowledge of one. Social Worker, Employee E7 stated that she first became aware of the situation that occurred with Resident R1 on in the morning of Monday April 21, 2024 during clinical meeting. Employee E7 stated that she met and interviewed Resident R1. Employee E7 stated that assignments sheets are gathered and she partners with unit manager to gather interviews and then sends this to the administrator. When Page 1 of 6 395715 395715 05/08/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0585 asked if Employee E7 interviewed any other residents on the alleged perpetrator, nurse aide Employee E6 Employee E7 stated that all the other residents were deemed non-interviewable. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18 (b)(1)(3)(2.1)(4) Management Residents Affected - Some 28 Pa. Code 201.29 (a) Resident Rights 395715 Page 2 of 6 395715 05/08/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for one of six residents reviewed. (Resident R1) Findings Include: Review of facility policy titled, Abuse Prevention Program revised December 2016 states, Policy Statement-Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of facility records revealed Resident R1 was admitted to the facility on [DATE]. The resident had the following diagnoses: Hemiplegia (paralysis to one side of the body), Morbid Obesity, and Atherosclerosis of Native Arteries of Extremities with Rest Pain (Right Leg). Review of facility grievance form titled, Resident/Family Concerns dated April 21, 2025 states, Concern-Nursing Concern states, Resident reported that she fell on 4/19/25 when [nurse aide Employee E6] attempted to hoyer her out of bed. She reported that she fell to the ground. Investigation section states, Date Initiated: 4/21/25 Date Competed was left blank next Section stated, Assignment sheet obtained, Employee E6 was the assigned nurse aide. This staff member resigned as of statements obtained from all other staff members. Review of facility investigation statements revealed an undated resident statement, Resident was interviewed regarding a report of fall from Hoyer. Resident reported early Saturday morning [Employee E6] was attempting to transfer her from bed to wheelchair using a Hoyer lift. As she was suspended in the air, she reported that she was suddenly on the floor. She reported falling on the right side of the bed next to the bathroom. Resident R1 reported that [Employee E6] called nurse aide [Employee E4] to assist her with getting her from the floor back into bed. When asked why she had not reported the fall sooner, she reported that when she fell, [Employee E6] said, Shhh I'll get fired, I have 8 kids. She stated that she reported the incident because her leg was hurting, and she found out [Employee E6] had resigned. Review of nurse aide, Employee E11 statement dated April 22, 2025 states When I came to work on 4-21-25 I had [Resident R1]. As I was doing AM care she told me that she fell. I asked how could you fall. She said they pick her up and put her in the bed. She told me what they looked like. I told the nurse. Interview with the Nursing Home Administrator held on May 8, 2025 at 1:34 p.m. revealed the Director of Nursing Employee E2 was on off Monday April 20, 2025 on the day Resident R1 reported the alleged abuse/neglect. The Nursing Home Administrator, Employee E1 stated he was working on April 21, 2025 and stated that the Social Worker Employee E7 was to enter the Incident into the Pennsylvania Electronic Event Report System as the social workers usually do. Employee E1 stated, I didn't follow up and that was my fault I should have but it was missed. 395715 Page 3 of 6 395715 05/08/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0609 The facility failed to enter the report of alleged abuse/neglect into the Pennsylvania Electronic Event Reporting System immediately of receiving the allegation from Resident R1. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.14(a)(c) Responsibility of licensee. Residents Affected - Some 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 395715 Page 4 of 6 395715 05/08/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to provide evidence that an allegation of abuse/neglect was thoroughly investigated for one of six residents reviewed. (Resident R1). Residents Affected - Few Findings Include: Review of facility policy titled, Abuse Prevention Program revised December 2016 states, Policy Statement-Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of facility grievance form titled, Resident/Family Concerns dated April 21, 2025 states, Concern-Nursing Received complaint by section is not checked off. Lists Writing, Verbal, During Resident Council, and Other all blank. Concern states, Resident reported that she fell on 4/19/25 when nurse aide Employee E6 attempted to hoyer her out of bed. She reported that she fell to the ground. Investigation section states, Date Initiated: 4/21/25 Date Competed is left blank Section states, Assignment sheet obtained, Employee E6 was the assigned nurse aide. This staff member resigned as of statements obtained from all other staff members. Review of facility records revealed Resident R1 was admitted to the facility on [DATE]. The resident had the following diagnoses: Hemiplegia (paralysis to one side of the body), Morbid Obesity, and Atherosclerosis of Native Arteries of Extremities with Rest Pain (Right Leg). Review of facility grievance form titled, Resident/Family Concerns dated April 21, 2025 states, Concern-Nursing Concern states, Resident reported that she fell on 4/19/25 when [nurse aide Employee E6] attempted to hoyer her out of bed. She reported that she fell to the ground. Investigation section states, Date Initiated: 4/21/25 Date Competed was left blank next Section stated, Assignment sheet obtained, Employee E6 was the assigned nurse aide. This staff member resigned as of statements obtained from all other staff members. Review of facility investigation statements revealed an undated resident statement, Resident was interviewed regarding a report of fall from Hoyer. Resident reported early Saturday morning [Employee E6] was attempting to transfer her from bed to wheelchair using a Hoyer lift. As she was suspended in the air, she reported that she was suddenly on the floor. She reported falling on the right side of the bed next to the bathroom. Resident R1 reported that [Employee E6] called nurse aide [Employee E4] to assist her with getting her from the floor back into bed. When asked why she had not reported the fall sooner, she reported that when she fell, [Employee E6] said, Shhh I'll get fired, I have 8 kids. She stated that she reported the incident because her leg was hurting, and she found out [Employee E6] had resigned. Review of statement dated April 22, 2025 states When I came to work on 4-21-25 I had Resident R1. As I was doing AM care she told me that she fell. I asked how could you fall. She said they pick her up and put her in the bed. She told me what they looked like. I told the nurse. Review of statement undated by Nurse aide Employee E4 states, When I worked with [Employee E6] I 395715 Page 5 of 6 395715 05/08/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was asked to help with [Resident R2] who I changed and helped show an easier way to change. Then I needed help with a change so I went in [room XXX] and [Employee E6] was pulling the covers over when I asked for her assistance. Review of an undated written statement from Licensed nurse Employee E5 stated, Resident AAO (alert and oriented) x 3 (person, place and time) reported to a care nurse that she fell Saturday when the girl who had that assignment attempted to transfer her from the bed to wheelchair, the girl did not have anyone with her in the room, while she lifted her up with the Hoyer, she slid, the next thing she noticed that she was on the floor. Resident states that the girl attempted to get her off the floor, she had difficulty because she was screaming her legs hurt, then the care nurse called another care nurse to help her out. Nurse supervisors was notified, she went into the room assessed the resident. Resident back of left leg with mild swollen and painful. She is able to move all extremities. Pain medication 650 mg (milligrams) given for pain. Doctor was made aware. New order for stat x-ray left leg. Continue review of the facility's investigation revealed no evidence that the facility attempted to call and interview the alleged perpetrator Nurse aide, Employee E6. No evidence the facility attempted to interview any other licensed nurses or nurse's aids across shifts for April 18, April 19, 2025, April 20, 2025 or April 21, 2025. No evidence the facility attempted to interview any other residents on Nurse, aide,Employee E6's assignment or on the unit. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(c) Nursing services 395715 Page 6 of 6