Health inspection·May 23, 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 review of facility policies, observation, interviews with residents and staff, it was determined the facility failed to promote care for residents that maintains or enhances dignity and respect related to privacy during treatment administration and ensuring residents' care and comfort is maintained by providing necessary necessities of bedding for two of eight residents reviewed. (Resident 4 and Resident 370) Findings include: Review of facility policy titled Abuse and Neglect dated March 2018, clinical protocol defines neglect as the failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish or emotional distress. Review of facility policy titled Activities of Daily Living (ADL) dated March 2018 revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Review of Resident R4's quarterly Minimum Data Set (MDS - federal mandated assessment tool for all residents) dated May 6, 2025, revealed that this resident was admitted into the facility on July 18, 2024 and required partial of moderate assistance with ADL's ( activities of daily living). The resident was assessed with a BIMS (Brief Interview of Mental Status) score of 12 indicating that this resident had moderate cognitive impairment. Review of Resident R4's clinical record revealed a physician order dated July 18, 2024, for the medication Lidocaine patch 5% to be administered daily to both shoulders topically one time a day for pain. Observation of medication administration on May 22, 2025, at 8:35 a.m. with Licensed nurse, Employee E13 revealed that Employee E13 prepared medications and administered the medication while the hallway to Resident R4. Licensed nurse, Employee E13, applied the Lidocaine patches to both of Resident R4's shoulders under the resident shirt, providing no privacy to the resident while in the hall, next to the activity room where six residents were observed watching television and other resident walking by toward the dining room for breakfast. Review of Resident R370's admission MDS dated [DATE], revealed that the resident entered the facility on May 14, 2025 with diagnosis' including, orthopedic condition (a condition that effects the Page 1 of 19 395715 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bones, joints and or muscles), and arthritis. The resident was assessed as dependent for ADLs (activity of daily living), the resident used a wheelchair. Continued review of the MDS revealed that the resident had a BIMS (brief interview of mental status) score of 14, which indicated that Resident 370 had intact cognitive functions. Observation of Resident R370 in his room on May 21, 2025, at 9:50 a.m. who resided on the 2nd Floor nursing unit revealed the resident lying on his plastic bed mattress with no sheets, no blanket, and no pillowcase. Interview with resident at time of the above observation revealed that the resident received care earlier that morning (estimate over an hour prior) and the employee left after stripping the bed, she has not yet returned. Interview with Nurse aide, Employee E15 on May 21, 2025, at 10:15 confirmed she was assigned to Resident R370 and provided care and stripped his bed earlier. This employee stated that she was unable to complete making the bed due to lack of supplies, Employee E15 stated that there were no linens available on the unit. Interview with Nurse aide, Employee E18 on May 21, 2025, at 10:35 a.m. confirmed this employee was also assigned to the 2nd floor nursing unit and had all available linens to make all the beds assigned to her. Interview with Nurse aide, Employee E20 May 21, 2025, at 10:55 a.m. confirmed he provided care on the 2nd floor for residents also and had no shortage of linens. Employee E20 described the process of collecting supplies for each resident. Observed was a linen closet with sheets and blankets folded. There are two linen cabinets on the floor and if they run low on supplies, the laundry room is located on the second floor, and supplies can be obtained there. Tour of the laundry room revealed on May 21,2025 at 11:00 a.m. revealed lines clean, folded, stored and available , this observation confirmed by laundry Employee E16 and Unit Manager E17 . 28 Pa.Code 201.29(j) Resident Rights 28 Pa Code 211.12(d)(1)(5) Nursing Services 395715 Page 2 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for one of two hospitalizations reviewed (Resident R117). Findings Include: Review of Resident R117's clinical record revealed a nursing progress note dated March 18, 2025, that indicated the resident was transferred to the local hospital for evaluation. Review of documentation provided by the Nursing Home Administrator on May 23, 2025, at 10:35 a.m. revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident R117's facility-initiated emergency transfers to the hospital as required until May 21, 2025. Interview on May 23, 2025, at 10:54 a.m. with the Nursing Home Administrator, Employee E1, confirmed the ombudsman was not made aware of Resident R117's hospital transfer on March 18, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management 395715 Page 3 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline care plan for one of two new admissions reviewed (Resident R319). Findings Include: Review of facility policy, Care Plan-Baseline dated 2001 revealed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admissions. Review of Resident 319's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of dementia (progressive degenerative disease of the brain). A comprehensive care plan which was initiated on May 12, 2025 did not indicate a baseline care plan for dementia. On May 21, 2025, at 1:48 p.m. an interview with the Director of Nursing, Employee E2 confirmed that Resident R319 did not have a baseline care plan. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services 395715 Page 4 of 19 395715 05/23/2025 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 a review of clinical records, and interviews with residents, family members, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming for 3 of the six residents reviewed (Residents R319, R62 and R45). Residents Affected - Few Findings: Review of Resident 319's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of dementia, muscle weakness, difficulty in walking, and osteoarthritis ( join disease that results in breakdown of join cartilage and underlying bone). A review of Resident R319's admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 7, reflecting severe cognitive impairment. A comprehensive care plan initiated on May 12, 2025, indicated: I have an ADL deficit due to cognitive deficits, impaired balance, and spinal fracture. Assistance of one person is required for transfers, bed mobility, toileting, bathing/washing, dressing/grooming, and self-care. Provide setup assistance with needed or desired items. Allow ample time for the resident to complete tasks. On May 20, 2025, at 12: 14 p.m. an interview was held with Resident 319 who was observed to have long nails. Resident R319 wanted her/his nails to be cut. On May 20, 2025, at 12:46 an confirmation of Resident R319 having long nails was confirmed by unit manager, Employee E5. On May 20, 2025, at 12:58 p.m., a family interview was held for nonverbal Resident R45, who was on receiving hospice services. The family member revealed that the resident needed a haircut, which had been brought to the facility's attention a few weeks prior, but the haircut had not yet been provided. It was further stated that his nails become long before someone cuts them and that it takes some time to get them cut. Review of Resident 45's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of dementia. A review of Resident R45's quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 99, meaning resident unable to participate in the cognitive interview due to severity of their severity of their impairment. On May 20, 2025, at 1:12 p.m. unit manager, Employee E5 confirmed the observations of resident having long nails and long hair. A comprehensive care plan dated May 4, 2025, was reviewed and revealed Resident R45 is a two person always assist with care. Dependent on staff for bathing washing, dressing/growing and self-care. On May 4, 2025, a facility developed a care plan for the resident to allow his/her nail to be filed down. A review of Resident R62's clinical record revealed that the resident was admitted to the facility 395715 Page 5 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on [DATE], with diagnoses including parkinsonism (a condition with movement-related symptoms like Parkinson's disease), difficulty walking, right hip pain, unsteadiness on feet, and orthostatic hypotension (a sudden drop in blood pressure when standing up from a sitting or lying position). A review of Resident R62's admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 3, reflecting severe cognitive impairment. The functional abilities section of the MDS indicated that Resident R62 requires maximum assistance with hygiene tasks. On May 20, 2025, at 11:23 a.m., Resident R62 was interviewed and observed to have facial hair and expressed a desire to be shaved. At 12:46 p.m. the same day, the unit manager, Employee E5, confirmed that the resident was in need of a shave. 28 Pa code 211.12.(d)(1)(5) Nursing services 395715 Page 6 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, clinical record reviews and interviews with staff, it was determined the facility failed to ensure that medically related social services were provided as required for four of eight residents reviewed related to routine care plan meetings. (Residents R60, R61, R68, R97) Residents Affected - Few Finds include: Review of facility policy titled Care Plans - Baseline dated March 2022 revealed the baseline plan includes instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care and must include minimum healthcare information necessary to properly care for the resident including but not limited to initial goals, physician orders, dietary orders, therapy services, social services, PASARR recommendations. The baseline care plan Is used until a staff can conduct the comprehensive assessment and develop interdisciplinary person standard comprehensive care plan the baseline care plan is updated as needed to meet the residents needs until the comprehensive care plan is developed. Review of Resident 60's clinical progress notes revealed this resident's last care plan meeting was held November 5, 2024. Participating in the care conference were representatives from Nursing, Dining Services, Recreation, and Social Services. Also participating in the Care Conference was Resident R'60's daughter. Further review of Resident R60's clinical record notes revealed that resident prior care conference meetings were dated August 9, 2024, June 25, 2024, and March 5, 2024. Review of Resident R61 clinical record revealed that this resident's last care conference was dated November 26, 2024. Participants in the care conference were nurse, dining, recreation, social services and resident's daughter. Review of Resident R68's clinical record revealed that this resident last care conference was held on November 5, 2024. Participating in the conference were representatives from nursing, dining services, recreation, and social services, also in attendance was Resident R68 POA (power of attorney). Medications and care plan were reviewed. Review of Resident R97's social service note revealed that this resident's last care conference was held on December 5, 2024, via conference call with resident's family and interdisciplinary team. Medication and care plan were reviewed. Interview with Resident R60's family member on May 20, 2025, at 12:43 p.m. revealed that she is dissatisfied with the social service communication. Resident R60 has not had a care plan meeting in over six months and there is not currently one planned. Interview with Social Service Director, Employee 24 on May 22, 2025, at 1:20 p.m. revealed that care conference should be held every quarter (every 3 months). Employee E confirmed that the care conferences have delayed due to shortness of staff in the department. 28 Pa. Code 201.14 Responsibility of Licensee 395715 Page 7 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0745 28 Pa. Code 211.16(a) Social services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395715 Page 8 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff interview, and pharmacy review recommendations, it was determined that the facility failed to act on the pharmacy recommendations in a timely manner for one of three residents reviewed (Resident R78). Findings include: Clinical record review revealed Resident R78 was admitted to the facility on [DATE], with a diagnosis that included but not limited to personal history of transient ischemic attach (TIA) (refers to it as a mini- stroke temporary blockage of blood flow to the brain), cerebral infarction, dementia, difficulty in walking, muscle weakness, unsteadiness on feet. Further review of Resident R78's clinical record revealed the physician ordered Diclofenac sodium external gel 1% apply to left hip and lower back topically four times a day for arthritis pain, apply 4 grams to left hip and lower back on January 14, 2025. During a drug regimen review on January 14, 2025, the pharmacist recommended that Voltaren Gel (Diclofenac Gel) should be administered as follow: lower extremities- apply 4 gram to affected area and upper extremities-apply 2 gram to affected area . Please add the gram strength to the directions for Voltaren Gel. During an interview on May 23, 2025, at 10:34 a.m., Director of Nursing E2 confirmed that the facility failed to implement the pharmacy recommendations for Resident R78, and recommendation had not been implement at all. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395715 Page 9 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, review of facility policies and interview with staff, it was determined that the facility failed to ensure that medications carts were kept locked and refrigerated medications kept dry and at proper temperatures on one of two nursing floors. (2nd Floor) Findings include: Review facility policy titled Medication Labeling and Storage revealed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light and only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanctuary manner. Compartments but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes containing medication biologicals are locked and such items or left are not left unattended if open or otherwise potentially available to others. Review of facility policy titled Administrating Medications revised 2012 revealed that during administration of medications, the medication cart will be kept closed and locked when out of sight of medication nurse or aide. It must be kept on the door away of the resident's room, with open drawers facing inward and all other sites closed. No medications or kept on top of the cart. The cart must be clearly visible to the personnel administrating medications, and all outward sides must be inaccessible to residents or others passing by. Observation on May 20, 2025 at 11:50 a.m. on the 2nd Floor revealed the cart assigned to Licensed nurse, Employee E22 was left unlocked. Employee E22 was observed coming out of a resident room at the end of the hallway. Interview with Licensed nurse, Employee E22 confirmed the cart was left unlocked. Observation on May 22, 2025 on the second floor nursing unit revealed that the low Cart assigned to Licensed nurse, Employee E23 was left unlocked. Interview with Nursing Supervisor, Employee E6 at time of above observation confirmed that cart was left unlocked. Interview with Licensed nurse, Employee E23 on May 22, 2025 at 9:12 a.m. revealed she was unaware the cart was unlocked. Observation of medication cart identified as middle cart on May 22, 2025 at 9:25 a. m. reveled Licensed nurse, Employee E13 leaving the cart unlocked while going to the kitchen on the nursing floor for supplies. Observation of the above confirmed by Nursing Supervisor, Employee E6 at time of the above observation. Observation of Second floor medication room on May 22, 2025 at 8:38 a.m. with Nursing Supervisor, Employee E6, revealed the medication refrigerator tempeture reading at 50 degrees and the top of the 395715 Page 10 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0761 Level of Harm - Minimal harm or potential for actual harm refrigerator frozen and dripping water onto the medications. All contents of the refrigerator were found to be wet. The observation above was confirmed by Nursing Supervisor, Employee E6 at time of the above observation Residents Affected - Few 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) nursing services 395715 Page 11 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

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 observations of the operations of the food and nutrition services department, reviews of policies and procedures and interviews with residents and staff, it was determined that the facility failed to ensure each resident received and the facility provided foods and drinks that were palatable, attractive and at a safe and appetizing temperature. Residents (R14,R3, R86, R115, R55, R85, R94, R94, R79). Residents Affected - Few Findings include: A review of the undated facility policy titled test tray evaluation revealed that the acceptable temperature for the hot food entree, starch and vegetables were 135 degrees Fahrenheit at point of service for the residents and the acceptable temperature for soup was 165 degrees Fahrenheit at point of service for the residents. The policy also indicated that the dietary department was responsible to ensure that accepatable temperatures were provided at point of service for the residents, to maximize food quality, palatability and safety the foods and beverages. Observations during the noon meal service of the foods and beverages on May 20, 2025, for the residents that were eating in the dining rooms or having tray delivery service to their rooms revealed that the main hot entree was listed as country fried steak and cream gravy. The residents did not receive the cream gravy as planned. The country fried steak was over-cooked or held hot for extended time. The residents and staff had difficulty cutting and chewing the country fried steak. Residents were heard asking for a substitute food item for their main entree that day; because the food was not palatable, attrative and appetizing. A review of the menus planned by the dietitian and prepared by the food and nutrition department staff, on May 20, 2025 revealed that all diets Regular, Mechanical, Pureed, Carbohydrate Controlled, Renal were preplanned to receive cream gravy with their meals. On May 22, 2025, at 10:30 a.m., a resident group meeting was held with nine alert and oriented residents (R14, R3, R86, R115, R55, R85, R94, R94, and R79). The residents reported that food is being served cold during all three meals-breakfast, lunch, and dinner. They stated that the food is difficult to chew, lacks flavor, and is not seasoned. Some residents also reported that they often request items from the alternative menu, which typically consists of sandwiches. A test tray evaluation was completed on May 22, 2025 and supported the residents concerns that the foods and fluids were not regularly being received and provided that were palatable, attractive and at safe and appetizing temperatures for resident satisfactiony. Observations of the meal tray pass for the residents eating in their rooms on the second floor nursing unit revealed a delay in passing food trays, the nursing staff. The corned beef and cabbage was tested at point of service to the residents and was 116 degrees Fahrenheit. Mashed potatoes were tested at point of service to the residents and were 100 degrees Fahrenheit. The director of dietary services, Employee E9, was present during the test tray evaluation on the second floor nursing unit and confirmed the delays, in meal tray pass. The low or tepid temperatures of the hot foods (below the established standard of 135 degrees Fahrenheit at point of service) was also confirmed with the food service director on May 22, 2025. A review of the pre-planned menu devised by the dietitian for May 22, 2025 revealed that lentil 395715 Page 12 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few soup was planned; however chicken noodle soup was prepared and served. Roasted carrots, potatoes and onions were planned; however mashed potatoes were served instead. Mixed fruit dump cake was planned; however corn bread was prepared and served for the residents. A dinner roll was planned with margarine; however it was not offered/served to the residents on this day. Interview with the director of dietary service, Employee E9, at 1:30 p.m., on May 22, 2025 confirmed that the recipe for country fried steak was not followed on May 20, 2025. The director of dietary services, Employee E9 also confirmed that the menu was not followed as planned on May 22, 2025. 28 PA. Code 211.12(a)(b)(c)(d) Resident care policies 28 PA. Code 211.12(c)(d)(3)(5) Nursing services 395715 Page 13 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

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 three of 21 residents. (R80, R15). Residents Affected - Few Findings Include: Review of Facility Policy: Foods Brought by Family/Visitors undated, states Food brought to the community by visitors and family is permitted. Community staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Safe food handling practices will be explained to family/visitors in a language and format they understand. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Contains will be labeled with the resident's name, the items and the use by date. On May 20, 2025, at 11:36 a.m., an observation conducted with the unit manager, Employee E5, revealed that Resident R15 had a personal refrigerator containing Chinese takeout food in Styrofoam container, red paper, and a peach. There was no temperature log to monitor the safe temperatures. It was further confirmed that the facility had not given her any guidance on how to maintain food in accordance with health and safety standards. On May 20, 2025, at 11:58 a.m., an observation conducted with the unit manager, Employee E5, revealed that Resident R80 had a personal refrigerator containing three food containers. The containers were not labeled with dates, and the refrigerator did not have a temperature log. Resident R80 stated that her family had provided the refrigerator, and that the facility had not given her any guidance on how to maintain food in accordance with health and safety standards. On May 21, 2025, at approximately 11:20 a.m., an interview was conducted with the Administrator, Employee E1, who confirmed that the facility allowed several residents to have personal refrigerators without providing guidance on how to maintain food in accordance with health and safety standards. On May 21, 2025, at 2:00 p.m., a follow-up interview was conducted with Resident R15, who expressed frustration that her Chinese food in a Styrofoam container, a peach, and a red paper item were frozen due to the refrigerator being at a freezing temperature. 28 Pa. Code 201.18(b)(1) Management 395715 Page 14 of 19 395715 05/23/2025 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, facility documentation, and staff interviews, it was determined the facility failed to implement appropriate tracking and surveillance of infection for two of 3 months reviewed April 2025 and May 2025. (Resident R97) Residents Affected - Few Findings include: Review of facility policy titled Infection Prevention and Controlled Manual dated February 2020, revealed the primary objective of the infection prevention control program is to provide an effective facility wide program that ensures that the facility develops implements and maintains an infection prevention and control program in order to prevent recognize, and control, to the extent possible, the onset and spread of the infection within the facility. The infection prevention and control program will perform surveillance, prevent and control outbreaks, use records of infection reports to improve its infection control process and outcomes by taking corrective actions as indicated, implement hand hygiene, and properly store handle process and transport linens. Review of National Health Care Safety Network NHSN tool for tracking healthcare associated infections titled Long Term Care Facility Component Manual dated January 2023 revealed surveillance is defined as an ongoing systematic collection comment analysts, interpretation, and this emanation of data. A facility infection prevention and control program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents' staff and visitors' information collected during surveillance activities can be used to develop and track prevention priorities for the facility. Review of Resident R97's nursing notes dated April 11, 2025, revealed that eye drainage was noticed by the nurse's aide, the eye was cleaned several times on this shift, but drainage continues. Spoke with medical doctor regarding right eye drainage. Medical doctor ordered polytime eye drops one drop in eye four times a day for one week. Review of resident physician orders revealed an order dated April 11, 2024, for the antibiotic Polytrim ophthalmic solution, with instructions to instill one drop in right eye four time a day for drainage from right eye. Further review of Resident R97's nurses notes dated April 18, 2025 revealed the resident has completed antibiotic poyltrim to right eye, no redness or drainage noted. Further review of Resident R97's nurses note dated May 7, 2025, revealed Resident R97 was seen by on site ophthalmologist. New orders as follows Ofloxacin (antibiotic eye drops) instill one drop every day in both eyes for seven days related to bacterial conjunctivitis. Continued review of resident clinical record physicians' orders revealed and an ordered dated May 8, 2025, for the antibiotic Ofloxacin with instruction to instill one drop in both eyes one time a day for bacterial conjunctivitis (pink eye, very contagious bacteria infection of the eye) for seven days Interview with Infection Preventionist, Employee E21 on May 22, 2025, at 1:02 p.m. confirmed the documentation that Resident R97 was diagnosed and treated for bacterial conjunctivitis and the infection tracking for the months of April 2025 and May 2025 did not reflect this resident's infection. 395715 Page 15 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0880 Resident 97 was not listed for having a bacterial infection. Employee E 21 stated she is uncertain of how that was missed in the months of April 2025 and May 2025 in infection tracking. Level of Harm - Minimal harm or potential for actual harm 28 Pa. code 211.10(d) Resident Care policies Residents Affected - Few 28 Pa. code 211.12(d)(1)(5) Nursing services 395715 Page 16 of 19 395715 05/23/2025 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 physical environment of the food and nutrition services department and interviews with staff, it was determined that essential equipment used to operate the main kitchen where foods and beverages were prepared for the residents was not in safe functional condition. Residents Affected - Few Findings include: The dish machine was not functioning to provide water hot enough for cleaning and sanitizing dishware's, utensils, pots, pans, cups, bowls, plates and mugs. The required final rinse temperature to clean and sanitize the dishware was 180 degrees Fahrenheit. Observations at 9:40 a.m., on May 20, 2025 of the final rinse temperature of the dish machine revealed the gauge and digital readings were was below the required temperature specified by the equipment manufacturer at 150 degrees Fahrenheit. Interview with the director of dietary services, Employee E9 at 9:45 a.m., on May 20, 2025 confirmed that the booster heater for the dish machine was not functioning. The director of dietary also confirmed that the water softener was not functioning for months either. Observations of the three compartment sinks revealed that the wells were in need of repair. The one well was not holding water. The sink stopper, piping and working mechanism underneath the sinks were leaking water all over this area. Observations of the food garbage disposal located adjacent to the three compartment sink revealed that this piece of equipment was not functioning according to manufacturers' specifications. The garbage disposal was spewing water onto the ceramic tiled flooring. The flooring contained deep groves with the missing grouting secondary to the water damaged tiles. The grouting on the tiled flooring in this area below the three compartment sink had been worn away from constant water leakage. The flooring contained deep groves secondary to the water damaged tiles. Observations of the grease trap that was located in the three compartment sink area revealed that it was out of commission and covered with a piece of soggy plywood. The continuous water leaking from the broken well of the three compartment sink and the constant spewing of the water from the broken garbage disposal unit saturated the plywood cover that had been placed over the broken grease trap that was installed in the floor of this area. Observations of the metal doors that open directly outdoors from the hallway located along side of the main kitchen were not sealing properly upon closing. There were noted gaps to the outside located at the threshold of the doors. Interview with the administrator, Employee E1 and the director of dietary services, Employee E9 at 10:00 a.m., on May 20, 2025 confirmed that essential equipment (dish washer, booster heater, water softener, garbage disposal, three compartment sink, grease trap and metal doors (adjacent to the main kitchen) leading directly outside the building) for the food and nutrition department was not maintained in safe mechanical and operational condition. 395715 Page 17 of 19 395715 05/23/2025 Wesley Enhanced Living at Stapeley 6300 Greene Street Philadelphia, PA 19144

F 0908 28 PA. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 PA. Code 201.18(b)(1)(3)(d)(e)(1)(2.1) Management Residents Affected - Few 395715 Page 18 of 19 395715 05/23/2025 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 Based on environmental observations of the food and nutrition services department, reviews of the consulting pest control operator's reports and interviews with staff, it was determined that the facility failed to maintain an effective pest control program for the building. Residents Affected - Few Findings include: Observations of the main kitchen, where foods and fluids are prepared, stored and assembled for delivery to the nursing units revealed that the flooring was in need of repair. The grouting was missing and worn away by water damage in the three compartment sink area. The flooring contained pooling of water and food debris from leaking and inoperatable equipment (sink, garbage disposal and grease trap). The water and food debris were nutrients for pests and rodents. Observations of the metal doors leading directly outdoors from the hallway near the main kitchen revealed that the doors were not sealing properly upon closing. There were noted gaps (one inch) located at the threshold of the doors. These doors opened to a driveway where the dumpster unit for trash and garbage was held for pick-up and disposal by an outside contractor. A review of the pest control operators reports for the months of February, 2025 through May, 2025 indicated that the facility, together with the main kitchen was treated for common household pests and rodents (mice, roaches and ants). Interview with the director of maintenance and housekeeping, Employee E7, at 11:30 a.m., on May 20, 2025 confirmed the repairs and cleaning that were necessary to ensure that the inside of the building was pest and rodent free. 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 395715 Page 19 of 19