Health inspection·August 14, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on review of facility documentation, review of facility policy and interview with resident, it was determined that facility did not ensure to report the results of all investigations within 5 working days to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency) for one of one resident reviewed. (Resident R38)Findings include:Review of facility policy ‘Resident Abuse & Neglect Prevention Program,' initiated on May 1st, 2023, under section 2. Identification and investigation of suspected abuse/neglect/misappropriation, indicates that the director of nursing services, administrator or social services designee will keep the resident and/or his/her representative informed of the progress of the investigation.Further review of policy, under section 3. Regulatory Reporting, indicates that the facility will report alleged and substantiated incidents to the Pennsylvania Department of Health, additional state agencies and/or local authorities per federal and state requirements.Review of facility reported event to the State Agency dated May 22, 2025, revealed and event type misappropriation of patient/resident property The facility reported Resident R38 missing money in the amount of $50.00 on May 21, 2025. Further review of the reportable event revealed that the event will be updated when investigation is completed. Interview with Resident R38 on August 12, 2025, at 1:20 pm, revealed that he received $50.00 from the facility on August 12, 2025.Review of facility reported events for month of May 2025, revealed the event related to Resident E38 misappropriation of property was rejected by the State agency on May 30, 2025, and was not re-submitted by the facility until August 12, 2025. 28 Pa Code 201.14(a) Responsibility of licensee Page 1 of 9 395757 395757 08/14/2025 Edgehill Nursing and Rehab Cen 146 Edgehill Road Glenside, PA 19038

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 two of three hospitalizations reviewed (Resident R9 and R5). Findings Include: Review of Resident R9's clinical record revealed a nursing progress note dated April 25, 2025, that indicated the resident was experiencing weight loss and dysphagia (difficulty swallowing) and was subsequently transferred to the local hospital for evaluation.Review of Resident R5's clinical record revealed a nursing progress note dated June 17, 2025, that indicated the resident had abnormal lab results was transferred to the local hospital for evaluation.Review of Resident R9's and R5's clinical record revealed no documented evidence that the Office of the State Long Term Care Ombudsman was made aware of unplanned hospital transfers.Interview on August 14, 2025, at 12:36 p.m. with Nursing Home Administrator, Employee E1, confirmed the ombudsman was not made aware of Resident R9's and R5's unplanned hospital transfers.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(2) Management 395757 Page 2 of 9 395757 08/14/2025 Edgehill Nursing and Rehab Cen 146 Edgehill Road Glenside, PA 19038

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 review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to develop and implement a person-centered comprehensive care plan for two of 24 residents reviewed related to activities of daily living and pressure ulcers (Resident R4 and R15).Findings include:Review of Resident R4's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 3, 2025, revealed the resident had moderate cognitive impairment and was frequently incontinent (loss of bowel or bladder control) of urine and always incontinent of bowel. Resident R4 had diagnoses of hemiplegia (paralysis of one side of the body) or hemiparesis (muscle weakness of one side of the body), anxiety (intense, excessive, persistent worry or fear), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), and rheumatoid arthritis (autoimmune disease typically affecting the joints causing pain, swelling, and stiffness).Review of Resident R4's comprehensive care plan revised August 1, 2025, revealed the resident required assistance for bathing, grooming, and personal hygiene. Interventions dated July 17, 2025, included to monitor for pain and medicate as appropriate prior to activity or rehabilitation.Review of documentation submitted by the facility to the State Survey Agency on July 1, 2025, revealed on July 1, 2025, Resident R4 reported that the nurse aide, Employee E6, tossed him/her around like a piece of meat.Continued review of facility documentation submitted to the State Survey agency on July 1, 2025, revealed upon facility investigation it was revealed that while nurse aide, Employee E6, attempted to provide incontinence care for Resident R4 the resident expressed that the aide was being rough, and the nurse aide continued to provide incontinence care without addressing patients concerns.Review of facility documentation revealed a statement by nurse aide, Employee E6, dated July 1, 2025, which revealed the employees recall of the incident reported by Resident R4.Review of nurse aide, Employee E6, statement dated July 1, 2025, revealed the nurse aide went into the room to change Resident R4 and had no knowledge of any of her condition and started to change her. Nurse aide, Employee E6, described Resident R4 as very fussy.Further review of facility documentation submitted to the State Survey agency on July 1, 2025, revealed Nurse aide, Employee E6, was further educated concerning resident rights and how to address resident pain.Interview on August 14, 2025, at 10:00 a.m. with nurse aide, Employee E5, revealed Resident R4 does tend to have discomfort during incontinence care. Nurse aide, Employee E5, reported being familiar with Resident R4 and knows how to approach/handle the resident. Nurse aide, Employee E5, reported if Resident R4 complains of pain during care to stop and further alert the nurse.Interview on August 14, 2025, at 11:20 a.m. with the Director of Nursing, Employee E2, confirmed there was no care plan developed to address Resident R4's pain during incontinence care prior to the incident with the resident and Nurse aide, Employee E6.Review of facility policy ‘Comprehensive Person-Centered Care,' reviewed March 2025, indicated that care plan will include focus, issues, problems, needs ( . physical .prevention of decline in condition) identified through resident involvement, direct observation, coordination, coordination of discipline observations and assessment. As each issue, problem or need is added to the care plan; a date will be recorded with the issue to document the specific time when the issue was identified.Review of R15's clinical record on Tuesday, June 12, 2025, at 2:00 pm, revealed Resident R15 was admitted with medical history of congestive heart failure, muscle weakness, stage three - chronic kidney disease, abnormal results of liver function studies, chronic atrial fibrillation, high blood pressure.Further review of Resident R15's clinical record revealed a nursing note, completed on June 12, 2025, at 10:45 pm, by licensed nurse Employee E14, stating resident has a Stage III (ulcer 395757 Page 3 of 9 395757 08/14/2025 Edgehill Nursing and Rehab Cen 146 Edgehill Road Glenside, PA 19038

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few involving thickness of skin loss, exposing tissue) pressure ulcer noted to sacrum.Resident heels are boggy. Review of a Nurse Practitioner's note dated June 12, 2025, at 8:00 pm, indicated Resident R15 had medical history of lymphedema (tissue swelling cause by tissue swelling) with recommendations for compression stockings and feet elevation.Further review of a Nurse Practitioner's note dated June 18, 2025, at 2:28 pm, revealed recommendation for heel boots when in bed.Further review of Nurse Practitioner's note dated July 2, 2025, at 2:32 pm, revealed preventative measures to float heels while in bed with use of pillows.Review of Resident R15's wound assessment, completed on June 18, 2025, by Nurse Practitioner, Employee E15, revealed a 3.10cm (centimeters) length, 5.40 cm width pressure ulcer/injury of right heel, noting that it was not acquired in house. Continued review of Employee E15 note revealed The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit.Review of Resident R15's care plan initiated on June 12, 2025, revealed the resident had actual impairment to skin integrity, and has potential for pressure ulcer development related to limitations in mobility. There was no evidence of facility developed and implementing interventions for recommended preventative measures of heel boots and float heels to prevent pressure injury in the resident's care plan. Interview with the Directo of Nursing on August 12, 2025, approximately 10:00 a.m. confirmed that the interventions of heel boots and for the resident's heels to be floated while in bed were not the resident's care plan. 28 Pa. Code 211.10 (c)(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services 395757 Page 4 of 9 395757 08/14/2025 Edgehill Nursing and Rehab Cen 146 Edgehill Road Glenside, PA 19038

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff and resident interviews it was determined that the facility failed to ensure care was provided in accordance with physician orders related to ACE wraps and cholecystostomy care for two of 24 residents reviewed (Resident R8 and R61). Findings Include:Review of Resident R8's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated July 3, 2025, revealed the resident was admitted to the facility on [DATE], was deemed cognitively intact, and had a diagnosis of heart failure.Review of Resident R8's comprehensive care plan revised July 17, 2025, revealed the resident was on diuretic (helps the body get rid of excess fluid) therapy for lower extremity edema (fluid retention).Review of Resident R8's clinical record revealed a skin and wound note dated July 2, 2025, that indicated due to comorbidities Resident R8 is at an increased risk of skin breakdown. Recommendations included to apply ACE wraps to lower extremities, from toes to below knees with instructions to apply in the morning and remove at night.Review of Resident R8's clinical record revealed a physician order dated July 4, 2025, which indicated to apply ACE wraps, in the morning, to lower extremities for edema.Continued review of Resident R8's clinical record revealed order administration notes dated July 8, July 9, July 10, July 15, July 16, July 17, July 18, July 19, July 22, and July 23, 2025, that Resident R8's ACE wraps were unavailable.Interview on August 11, 2025, at 12:45 p.m. with Resident R8 revealed staff could not find the ACE wraps and subsequently they were not being applied.Review of Resident R61's comprehensive MDS dated [DATE], revealed the resident was admitted to the facility on [DATE], and had a diagnosis of acute cholecystitis (inflammation of the gallbladder).Review of Resident R61's comprehensive care plan dated August 13, 2025, revealed the resident was at risk for infection post-surgical cholecystostomy (minimally invasive procedure used to drain fluid from the gallbladder) tube placement. Interventions included to monitor for signs/symptoms of infection.Review of Resident R61's clinical record revealed a physician order dated July 29, 2025, to call the physician if the cholecystostomy drainage bag output is less than 25 cc/day.Review of Resident R61's treatment administration record revealed on August 1, August 5, August 7, August 8, and August 9, 2025, nursing staff documented less than 25 cc output of the cholecystostomy drainage bag.Review of Resident R61's clinical record revealed no documented evidence that the physician was made aware when the cholecystostomy drainage bag output was less than 25 cc/day for the above dates. 28 Pa. Code 211.12(d)(1) Nursing services Residents Affected - Few 395757 Page 5 of 9 395757 08/14/2025 Edgehill Nursing and Rehab Cen 146 Edgehill Road Glenside, PA 19038

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of four residents observed during medication administration (Residents R2, and R29).Findings include: Review of physician orders for Resident R2, indicated an order dated, [DATE], for the following: Tylenol Oral Tablet 325 MG (Acetaminophen), give 2 tablet by mouth three times a day for Pain.On [DATE], at 8:43 a.m., observed that Employee E12, a Licensed Nurse, decanted Acetaminophen 325 MG (milligrams) two tablets, with expiration date [DATE], among other medications as ordered, and was initiating to administer it. Employee E12 was prevented from administering the Acetaminophen 325 MG two tablets to R2, as those medications were expired by date.At the time of the observation, interview with Licensed nurse, Employee E12, confirmed the above finding.On [DATE], at 9:24 a.m., review of physician orders for Resident R29, indicated order dated [DATE], for the following: Sitagliptin Phosphate Oral Tablet 100 MG, give 1 tablet by mouth, one time a day for DMII (Diabetes Mellitus Type II, also known as type 2 diabetes. It's a metabolic disorder where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels).On [DATE], at 9:28 a.m., observed that Employee E13, a Licensed Nurse, searched for the medication Sitagliptin Phosphate Oral Tablet 100 MG, (Brand Name: Januvia), for Resident R29, but could not find it in the medication cart. Employee E13 requested the supervisor to look for the medication Sitagliptin Phosphate Oral Tablet 100 MG for Resident R29 in the medication Pyxis, (Pyxis is an automated medication dispensing system used in healthcare facilities to improve medication safety and efficiency). But the nursing staff could not find the medication, Sitagliptin Phosphate Oral Tablet 100 MG for Resident R29. Eventually, Sitagliptin Phosphate Oral Tablet 100 MG, was not administered to Resident R29.At the time of the observation, interview with Employee E13, confirmed the above findings.The facility incurred a medication error rate of 6.9%. 28 Pa Code 211.12(d)(1)(2)(5) Nursing Services Residents Affected - Few 395757 Page 6 of 9 395757 08/14/2025 Edgehill Nursing and Rehab Cen 146 Edgehill Road Glenside, PA 19038

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interviews and a review of employee personnel file, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employee E10).Findings include: Interview on August 11, 2025, at 12:24 p.m. with the Nursing Home Administrator, Employee E1, revealed the Registered Dietitian was employed by the facility part-time. Review of Food Service Directors, Employee E10, personnel file revealed the employee held the position of Director of Dining Services with a start date of October 3, 2024. Job responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Review of the Food Service Directors, Employee E10, personnel file revealed Employee E10 obtained his/her ServSafe Certification on November 20, 2025. Continued review of Food Service Directors, Employee E10, personnel file revealed the employee was not a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution. Interview on August 12, 2025, at 12:06 p.m. with [NAME] President of Culinary & Nutrition Services, Employee E16, confirmed the Food Service Director, Employee E10, only had a ServSafe certification. Review of the specifications for ServSafe certification revealed this certification covers topics and education pertaining to food safety, not inclusive of food service management. Review of Food Service Directors, Employee E10's, credentials indicated that Employee E10 did not meet the statutory qualifications of a director of food and nutrition services. 201.14 (a) Responsibility of licensee. 395757 Page 7 of 9 395757 08/14/2025 Edgehill Nursing and Rehab Cen 146 Edgehill Road Glenside, PA 19038

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 documentation, observations, and staff interview it was determined that the facility failed to ensure food was stored and prepared in accordance with standards for food service safety. Findings Include:Review of facility policy Refrigerator and Frozen Food Storage undated, and facility policy Dry Storage, undated, revealed all food items should be labeled, dated, and sealed.A tour of the main kitchen was conducted on August 11, 2025, at 9:27 a.m. with the Assistant Food Service Director, Employee E11, which revealed the following:Observations inside the reach in refrigerator revealed two opened containers of thickened juices that had no open date. Per the specifications on the boxes, the juices should be consumed within seven days of opening. Further observations inside the reach in refrigerator revealed two black serving trays being used to store milk. The trays were observed to have a significant build up of milk that was sticky to touch.Observations in the dry storage area revealed cereal that was taken out of its original packaging and stored in facility bowls/lids with no open or use by dates. 201.14 (a) Responsibility of licensee. 395757 Page 8 of 9 395757 08/14/2025 Edgehill Nursing and Rehab Cen 146 Edgehill Road Glenside, PA 19038

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of policies, procedures, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with the cleaning techniques for medical equipment on two of two residents observed during Medication Administration review (Resident R51 and Resident 29).Findings include:Review of facility policy on Preparing for Medication Administration, undated, indicated; Prior to beginning medication administration pass, ensure that the medication cart is well stocked with the required supplies; vital sign equipment is cleansed before and after each resident use.On August 12, 2025, at 9:08 a.m., during medication administration to Resident R51, a Licensed Practical Nurse (LPN), Employee E12, used the Sphygmomanometer (an instrument for measuring Blood Pressure), without disinfecting it, before and after checking the Blood Pressure of R51. On August 12, 2025, at 9:14 a.m., E12 confirmed the findings.On August 12, 2025, at 9:28 a.m., during medication administration to Resident R29, a Licensed Practical Nurse (LPN), Employee E13, used the Sphygmomanometer, without disinfecting it, before and after checking the Blood Pressure of R29. Also, on August 12, 2025, at 9:55 a.m., during medication administration to Resident R42, Employee E13, used the Sphygmomanometer, without disinfecting it, before and after checking the Blood Pressure of R42. On August 12, 2025, at 9:59 a.m., E13 confirmed the findings.28 Pa Code 211.12 (d)(1)(5) Nursing services Residents Affected - Few 395757 Page 9 of 9