Health inspection·November 3, 2023

F 0610 Level of Harm - Minimal harm or potential for actual harm Further review of the investigation revealed no evidence that the facility interviewed or obtained written statement from the other employee who assisted Employee E7 to transfer Resident R77 on May 22, 2023. Investigation also revealed no documented evidence if the resident was wearing appropriate footwear or socks. There was also no documented evidence of the type of assistance the other employee provided during the transfer. Residents Affected - Few Interview with the Director of Nursing, Employee E2, on November 3, 2023, at 11:45 a.m. confirmed that the facility did not obtain statement from the orientee who provided assistance for Resident R77 on May 22, 2023. Employee E2 also confirmed that the facility investigation did not reveal evidence if the resident was provided appropriate foot wear or socks. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Philadelphia Protestant Home 6500 Tabor Road Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record reviews 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 and discharges as required for three of 22 residents reviewed (Residents R28, R21 and R75). Findings include: Review of progress notes for Resident R28 revealed a health status note, dated September 10, 2023, at 11:45 p.m. which indicated that the resident had a change in condition including shortness of breath and low oxygen levels and was ordered by the on-call nurse practitioner to be transferred to a local hospital emergency department for further evaluation. Review of progress notes for Resident R21 revealed a transfer to hospital summary note, dated June 6, 2023, at 2:38 p.m. which indicated that the resident had abnormal labs and was ordered by the nurse practitioner to be transferred to a local hospital emergency department for further evaluation. Review of progress notes for Resident R75 revealed a health status note, dated September 17, 2023, at 6:20 p.m. which indicated that the resident had an x-ray result that was positive for an acute hip fracture and was ordered by the practitioner to be transferred to a local hospital emergency department for further evaluation. Further review for Residents R28, R21 and R75's clinical records revealed that there was no indication that the Office of the State Long-Term Care Ombudsman was notified of the above facility-initiated emergency transfers. Interview on November 2, 2023, at 1:17 p.m. the Director of Nursing revealed that the facility did not have a policy regarding facility-initiated transfers and discharges. Continued interview confirmed that the Office of the State Long-Term Care Ombudsman was not notified in a timely manner as required of facility-initiated emergency transfers and discharges. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Philadelphia Protestant Home 6500 Tabor Road Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, clinical record review, facility policy review, drug information review and interviews with staff, it was determined that the facility failed to ensure that the medication error rate was less than five percent (%). Two medication errors out of 25 medication administration opportunities observed during medication administration (Medication Error Rate of 8%). Residents Affected - Few Findings include: The facility's medication error rate was 8% based on observation of 25 medication administration opportunities with two errors observed. Review of physician order for Resident R45 dated March 31, 2021, revealed an order for Polyethylene Glycol 3350 powder to give 17 grams once daily for constipation, mix in 6 ounces of liquid. Further review of the physician order dated September 20, 2021, revealed an order for Hormel Med Pass liquid (Nutritional supplement liquid) to give 4 oz three times daily. Review of physician order for Resident R61 dated December 20, 2022, revealed an order for Lidocaine external 4% patch (medicated patch to relieve pain) apply in the morning and remove after 12 hours. Patch to be removed according to the applying schedule. Review of Medline (national library of medicines) drug information, available at https://medlineplus.gov/druginfo/ revealed that Never apply more than 3 of the lidocaine 5% patch or lidocaine 1.8% topical systems at one time, and never wear them for more than 12 hours per day (12 hours on and 12 hours off). If you wear too many lidocaine transdermal patches or topical systems or wear them for too long, too much lidocaine may be absorbed into your blood. In that case, you may experience symptoms of an overdose. Observation of the morning medication pass for Resident R45 on November 2, 2023, at 9:38 a.m., with Employee E8, licensed practical nurse, revealed that Employee E8 took 17 grams of Polyethylene Glycol 3350 powder in a cup and mixed it with one ounce of juice. Employee also had 4 oz of Nutritional supplement liquid with her when she entered Resident R45's room for medication administration. Observation of the morning medication pass for Resident R61 on November 2, 2023, at 9:54 a.m., with Employee E8, licensed nurse, revealed that Employee E8 removed the old patch that was still applied on residents' right knee from previous application. Employee E8 then applied the new patch right after removing the old patch. Interview with Licensed nurse, Employee E8 on November 2, 2023, at 10:07 a.m., confirmed that the staff should have removed the lidocaine patch that applied on previous day for Resident R61. Employee R8 also confirmed that she only mixed the Polyethylene Glycol 3350 powder in one ounce of liquid not in 6 ounce as ordered by the physician. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12 (d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Philadelphia Protestant Home 6500 Tabor Road Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 observations, interviews with staff, and a review of facility policies, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety. Findings Include: Review of facility policy titled, Food and Supply Storage dated 1/23 states, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Further review of the policy reads, Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy by or use by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded. Initial tour of the dietary department completed on November 1, 2023 at 10:06 a.m. with the Director of Dining Employee E4 and Dietary Manager Employee E5. Observation of the walk-in refrigerator on November 1, 2023 at 10:19 a.m. revealed two bags of cheese cubes opened, unlabeled, with no open date or use by date. Two lunch meat ham opened, unlabeled, with no open date or use by date. Two lunch meat ham labeled with a use by date of October 30, 2023. One American cheese opened, unlabeled, with no open date or use by date. One mozzarella cheese opened, unlabeled, with no open date or use by date. Observation of the walk-in freezer on November 1, 2023, at 10:26 a.m. revealed a package of turkey burgers opened, unlabeled, with no open date or use by date and a bag package of pork sausage opened, unlabeled, with no open date or use by date. The above findings were confirmed by the Director of Dining, Employee E4 on November 1, 2023 at 10:28 a.m. 28 Pa. Code: 201.14 (a) Responsibility of licensee 28 Pa. Code: 201.18(e) (1) Management 28 Pa. Code 201.18(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Philadelphia Protestant Home 6500 Tabor Road Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to assess the need for specialized occupational therapy services according to the professional standards of practice for one out of one resident reviewed for rehabilitation services (Resident R82). Residents Affected - Few Findings include: Review of facility policy Therapy Screen dated February 8, 2023, revealed that Therapy screens are to be initiated when a resident may benefit from PT, OT or ST services. When a change in a resident's condition or a new need is identified a rehab screen is initiated. Request for Rehab Screen form will be completed by the clinical team member requesting the screen. Rehab director will initiate screen with appropriate discipline to determine resident's needs and document outcome of screen. A dining observation completed on November 1, 2023, at 11:39 a.m. in fourth floor dining room, revealed that Resident R82 was attempting to drink juice from a can which was placed on the table without using his arm or holding the can in his hand/s. Resident leaned to the table with juice on it and appeared struggling to drink the liquid. Further observation of Resident R82 revealed that the resident was provided with regular utensils, spoon and fork. Resident was observed with severe shaking while he was scooping and feeding himself. Resident appeared to have struggled to hold the utensils properly in his hand due to severe shaking. Review of dietician progress note dated October 26, 2023, revealed that an occupational therapy (OT) screen was requested due to staff reported concern of shaking with beverages. It was documented that the resident might benefit for adaptive cup and a message was left for Rehab Director. During an interview on November 3, 2023, at 9:30 a.m. with Director of Therapy, Employee E9 stated that Resident R82 was not on the case load and the resident was not screened by OT. Employee E9 also confirmed that there was no documented screen available with the therapy department for Resident R82. During an interview on November 3, 2023, at 9:56 a.m. with Dietician, Employee E10, stated she requested a therapy screen for Resident R82 for his tremors. Employee E10 stated she observed Resident R82 when he was eating, he would benefit from adaptive equipment. During an interview, on November 3, 2023, at 10:45 a.m. with Registered Nurse, Employee E11 stated that the resident had tremors during eating and he was using regular utensils. Employee E11 also confirmed that there was no screen placed as recommended by the dietician. 28 Pa Code: 201.18(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Philadelphia Protestant Home 6500 Tabor Road Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 that the facility failed to implement appropriate tracking and surveillance of infection for seven of seven months reviewed. (April 2023 to October 2023) Residents Affected - Few Findings Include: Review of Facility policy Infection Control dated October 2022 revealed that The objectives of our infection control policies and procedures are to: a. Investigate, control, and prevent infections in the facility. It shall be the responsibility of the Quality Assessment and Assurance committee, through the infection control committee, to assure that infection control policies and procedures are implemented and followed. Further review of the facility infection control policies available for review at the time of survey revealed no evidence of facility practices, tools, or protocols related to ongoing systematic collection, analysis, interpretation, and dissemination of resident infection in the facility. Review of National Healthcare Safety Network(NHSN) tool for tracking healthcare -associated infections titled Long-Term care facility Component Manual dated January 2023, revealed, Surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) 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. Surveillance may include process surveillance and outcome surveillance. Process surveillance includes reviewing practices by healthcare workers directly related to resident care to identify whether facility infection prevention and control policies are being followed. Examples may include hand hygiene adherence, appropriate use of personal protective equipment such as gowns, gloves, and facemasks, adherence to safe injection practices, and infection prevention and control practices used during wound care. Using outcome surveillance, facilities incorporate infection criteria, such as those provided to NHSN users, to identify and report evidence of suspected or confirmed healthcare associated infection or communicable disease. Examples of outcome surveillance include monitoring staff and residents for infection events, which may be indicative of an outbreak or a complication as a result of care received in the facility, such as C. difficile infection or urinary tract infection. A facility that conducts targeted surveillance, also referred to priority directed surveillance, focuses surveillance activities on high risk, preventable, and/or high consequence infections significant to their resident population. For example, by focusing on device associated infections in high-risk units, such as skilled nursing or ventilator-dependent, facilities are able to implement prevention measures to reduce infection risks among residents in those units. Another example of targeted surveillance is monitoring epidemiological significant organisms, such as multi-drug resident organisms (for example, MRSA, VRE, and CRE) or C. difficile among residents in the facility. By focusing staff time and resources on a smaller number of clinically important events, more time is available for detailed data collection and analysis to identify trends and opportunities for prevention. Since targeted surveillance methods may result in missed infections and potential outbreaks, facilities should have a facility-wide process in place to detect outbreaks and multi-drug resistant organisms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Philadelphia Protestant Home 6500 Tabor Road Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm A request was made to Infection Control Nurse, Employee E3 for infection tracking of the facility on November 2, 2023, at 1:09 p.m., for facility infection tracking log for COVID-19 and other infections. Review of facility documentation revealed that no infection tracking for non-COVID-19 infection were available. Residents Affected - Few Review of infection control meeting minutes dated July 27, 2023, revealed that the facility had nosocomial infection rate of 1.32%. which included three respiratory infections, one urinary tract infection, two cellulitis, and two skin infections. There was no other infection tracking or report available for July, August, September and October. Interview with Director of Nursing, Employee E2 on November 3, 2023, at 9:30 a.m., confirmed that the facility did not have evidence of infection surveillance and facility identified the non-compliance and was in the process of implementing infection surveillance/tracking. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Philadelphia Protestant Home 6500 Tabor Road Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system to effectively monitor antibiotic usage for seven of seven months of antibiotic stewardship program data reviewed. (April 2023 to October 2023). Residents Affected - Few Findings include: A review of facility policy entitled Antibiotic Stewardship, dated July 2023, revealed To ensure infections are evaluated and treatments ordered only when specific criteria for infection is met. In the event a resident is symptomatic for an infection, the resident will be added to the infection surveillance log, then staff will: f. Follow McGeer criteria for determining an HAI. If necessary, report to PA=PSRS and inform responsible party in writing. k. Surveillance on affected units for new cases of affected organism will be done by ICP/DON) A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary for implementing successful ASPs.2 CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Integrate the dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship in nursing homes. Pharmacists can provide assistance in ensuring antibiotics are ordered appropriately, reviewing culture data, and developing antibiotic monitoring and infection management guidance in collaboration with nursing and clinical leaders. Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions. Some antibiotic use measures (e.g., prevalence surveys) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Philadelphia Protestant Home 6500 Tabor Road Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few provide a snap-shot of information; while others, like nursing home initiated antibiotic starts and days of therapy (DOT) are calculated and tracked on an ongoing basis. Selecting which antibiotic use measure to track should be based on the type of practice intervention being implemented. Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT. At the time of the survey ending November 3, 2023, the facility failed to demonstrate their actions designed to implement an effective antibiotic/antimicrobial stewardship program which includes a system to effectively monitor antibiotic usage and prevent inappropriate use of antibiotic. Facility did not submit evidence of ASP program, surveillance, tracking, analysis which was requested to Infection Control Nurse, Employee E3 on November 2, 2023, at 1:09 p.m. Facility submitted two months of pharmacy generated Antibiotic Class Medication report which did not include the actions designed to implement an effective antibiotic/antimicrobial stewardship program which includes a system to effectively monitor antibiotic usage and prevent inappropriate use of antibiotics. An interview with the Director of Nursing, Employee E2, November 3, 2023, at 11:30 a.m. confirmed that there were no documented evidence of an effective antibiotic stewardship program and system of appropriate use of antibiotics as required. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Philadelphia Protestant Home 6500 Tabor Road Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interview, it was determined that the facility failed to ensure residents received pneumococcal immunizations for three of five residents reviewed for immunization concerns (Resident R47, R92 and R53). Residents Affected - Some Findings include: Clinical record review for Resident R47 revealed that the resident was admitted to the facility on [DATE]. Resident 47's clinical record contained no documented evidence that the facility administered or offered the pneumococcal vaccine; or evidence that Resident R47 had received the pneumococcal vaccine before her admission to the facility. Clinical record review for Resident R92 revealed that the resident was admitted to the facility on [DATE]. Resident 92's clinical record contained no documented evidence that the facility administered or offered the pneumococcal vaccine; or evidence that Resident R92 had received the pneumococcal vaccine before her admission to the facility. Clinical record review for Resident R53 revealed that the resident was admitted to the facility on [DATE]. Resident 53's clinical record contained no documented evidence that the facility administered or offered the pneumococcal vaccine; or evidence that Resident R53 had received the pneumococcal vaccine before her admission to the facility. Interview on November 2, 2023, at 1:09 p.m. with the Infection Control Nurse, Employee E3, stated every resident will be offered pneumococcal vaccine upon their admission to the facility. A resident's history of receiving vaccine in the community or if a resident decline vaccine would be documented in the clinical record. Employee E3 confirmed that there was no documented evidence that pneumococcal vaccine was offered, given or history was documented for Resident R47, R92 and R53. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395961 If continuation sheet Page 11 of 11