Health inspection·May 21, 2025

F 0628 Level of Harm - Potential for minimal harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for two of three sampled residents who were transferred to the hospital. (Residents 7, 16) Findings include: Clinical record review revealed that Resident 7 was transferred to the hospital on March 22, 2025, after a change in condition. There was no documentation to support that the resident and the resident's responsible party or legal representative were provided with written information regarding the transfer to the hospital. Clinical record review revealed that Resident 16 was transferred to the hospital on December 23, 2024, after a change in condition. There was no documentation to support that the resident and the resident's responsible party or legal representative were provided with written information regarding the transfer to the hospital. In an interview on May 21, 2025, at 12:20 p.m., the Administrator confirmed that there was no evidence that the residents and residents' representatives were given written notices regarding the identified transfers. 28 Pa. Code 201.14(a) Responsibility of licensee. Page 1 of 3 395800 395800 05/21/2025 Highlands at Wyomissing 2000 Cambridge Avenue Wyomissing, PA 19610

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) within 14 days after the facility completed the resident assessment for one of three sampled residents who were discharged from the facility. (Resident 45) Residents Affected - Few Findings include: Clinical record review revealed that Resident 45's discharge MDS assessment was completed on December 20, 2024, but had not been exported as of May 20, 2025. In an interview on May 21, 2025, at 11:00 a.m., Registered Nurse 1 confirmed that the MDS assessment had not been exported. 395800 Page 2 of 3 395800 05/21/2025 Highlands at Wyomissing 2000 Cambridge Avenue Wyomissing, PA 19610

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, and staff and resident interview, it was determined that the facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units. ([NAME] Court, units 100, 200, and 300) Findings include:Review of documentation by the American Burn Association's Burn Prevention Committee entitled, Scald Injury Prevention, revealed that a scald injury occurred when a hot liquid damaged one or more layers of skin and hot beverages were a frequent source of scald burns. Older adults were the most frequent victims of scald injuries due to thin skin, reduced mobility, and reduced ability to feel heat. Hot liquid at a temperature of 155 degrees Fahrenheit (F) could result in a scald injury in one second.Review of the facility policy entitled, Service Temperatures, last reviewed July 2024, revealed that staff were to ensure that temperatures were within critical limits and that coffee was to be a minimum of 150 degrees F and a maximum 180 degrees F. The policy indicated that hot beverages could be served at temperatures greater than 155 degrees F, contrary to the safety parameters outlined by the American Burn Prevention Committee.Observation during a test tray audit conducted on May 20, 2025, at 11:53 a.m., at the time the last resident meal tray was served, it was determined that the coffee provided on the tray was 179 degrees F. In an interview during the tray audit, Dietary Manager (DM) 1 confirmed the temperature of the coffee was 179 degrees F and that temperature was excessively hot for coffee at the point of service.In an interview on May 20, 2025, at 12:04 p.m., Dietary Aide (DA) 1 stated that she did not test the temperature of the coffee before the start of service or before the trays left the kitchen. She also stated that she did not typically test the temperature of the coffee before service to residents. There was a lack of evidence to support that any staff were testing the temperature of the coffee before service to residents.In an interview on May 20, 2025, at 1:20 p.m., DM 1 stated that Residents 1, 3, 4, 8, 14, and 23 typically ordered and drank coffee from the dietary department on a regular basis.In an interview on May 20, 2025, at 1:30 p.m., the Administrator stated that the facility did not have a procedure in place to assess a resident's ability to safely manage hot beverages.In interviews on May 20, 2025, at 4:10 p.m., and 4:22 p.m., Residents 4 and 8 stated that the coffee was often served hot and they could not drink it when served.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management. Residents Affected - Few 395800 Page 3 of 3