Inspection·July 13, 2023

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 Based on a review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to timely address and notify the physician of a significant weight change of two of the 20 residents reviewed (Resident 28 and 51). Residents Affected - Few Findings include: Review of the facility's policy titled Weights, last reviewed on February 8, 2022, revealed all residents are weighed on admission, weekly x four, monthly as a means of monitoring nutrition. Compare the weight to the last recorded weight, if a gain or loss falls within the parameters below, reweight. Parameters for evaluation of the significance of unplanned and undesired weight loss are as follows: 1 month-5% is significant weight loss, greater than 5% is severe loss; 3 months-7.5% is significant weight loss, greater than 7.5% is severe loss; and 6 months-10% is significant weight loss, greater than 10% is severe loss. If the resident falls within the parameters listed above, notify the Dietitian. Interview conducted with the Director of Nursing on July 12, 2023, at 1:00 p.m., revealed nursing is responsible for notifying the physician of a significant weight change in the residents. Review of Resident 28's diagnosis list revealed aftercare following explantation of left knee joint prosthesis, and Sepsis (body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage, and death). Review of Resident 28's weights and vitals revealed a weight of 246.8 lbs. on June 24, 2023, and 191 lbs. on June 30, 2023, 55.8 lbs. (22.61%) weight loss in six days. The resident's weight was not checked until July 11, 2023, which had a result of 189.4 lbs. Review of the nursing progress notes dated June 30, 2023, revealed admission weight marked as 264 pounds, the last weight noted in epic (hospital record) was 265 pounds on June 17, 2023. The resident was weighed yesterday via the total lift at 191 pounds. Will continue to monitor. Further review of Resident 28's clinical records review failed to reveal the identified significant weight change was timely addressed, and physician notified. Interview with Employee E7, Dietician was conducted on July 12, 2023, at 12:40 p.m. Employee E7 reported that she/he consulted the resident on July 6, 2023, for an abnormal Albumin level but was not notified of the significant weight loss of the resident. Interview conducted with the DON on July 13, 2023, at 10:00 a.m., confirmed that the physician was not notified of Resident 28's significant weight change. Review of Resident 51's weights and vitals revealed a weight of 252.6 lbs. on June 19, 2023, and 238.1 lbs. on July 3, 2023, a 14.5 lbs. (7.78%) weight loss in two weeks. Further review of Resident 51's clinical records review failed to reveal the identified significant weight change was timely addressed, and physician was notified. Interview conducted with the DON on July 13, 2023, at 10:00 a.m., confirmed that the physician was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395974 If continuation sheet Page 2 of 5 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 395974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monticello House 1048 W Baltimore Avenue Media, PA 19063 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 0684 not notified of Resident 51's significant weight change. Level of Harm - Minimal harm or potential for actual harm The facility failed to ensure Resident 28's and 51's significant weight change was timely addressed, and physician was notified. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/19/22 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395974 If continuation sheet Page 3 of 5 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 395974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monticello House 1048 W Baltimore Avenue Media, PA 19063 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to obtain physician orders for dialysis services for one of one resident reviewed (Resident 57). Residents Affected - Few Findings include: Review of Resident 57's clinical record revealed the resident was admitted to the facility on [DATE]. 2023, with diagnoses including Renal Failure. Review of Resident 57's care plans revealed, Resident 57 received dialysis every Tuesday, Thursday, and Saturday. Review of Resident 57's clinical record failed to reveal as of July 12, 2023, a physician's order for the resident to receive dialysis services. Interview with the Nursing Home Administrator and Director of Nursing on July 13, 2023, at approximately 2:30 p.m. confirmed, Resident 57 has been receiving dialysis treatments three times each week since hisher admission on [DATE]. 2023, but there was no physician's order for dialysis treatment obtained until July 13, 2023. The facility failed to ensure Resident 57 had a physician order for Dialysis services that resident receives three times a week. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395974 If continuation sheet Page 4 of 5 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 395974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monticello House 1048 W Baltimore Avenue Media, PA 19063 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 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 policy, observations and staff interview, it was determined that the facility failed to prepare food under sanitary conditions in one of four dining rooms. (5th floor) Residents Affected - Some Findings include: Review of facility policy, Single use gloves and hair restraints, policy revised date May 20, 2019, revealed that beard restraints are to be worn if facial hair growth is more than ½ inch long. This includes goatees as well. Hair restraints (including hair net or a hat). are to be worn during meal service in the pantries, while food is actively being prepared, served or cooked. Observation on July 10, 2023, at 12:15 p.m. during the lunch meal revealed two dietary staff (E4 and E5) bringing plated food from the pantry without beard guards. Observations also included the food was being delivered from the pantry without a lid and placed on trays to be delivered to resident rooms. The tray cart was in the dining room were residents were seated. Observation of the pantry revealed a tray line (where the food is plated) and a room that contained a trash can and dirty plates and trays from the previous meal. Dietary Aide E4 and E5, would take one plate at a time from the tray line, through the room, to the dining room and place it on the tray cart and then a lid would be placed over the food. Observation conducted on fifth floor dining room revealed dietary staff, employee E6, enter dining room then wipe nose using gloved right hand. Employee E6 proceeded to nearest table to assist two residents with meal items. Employee E6 used residents' utensils to cut food items and moved a baked potato using the same glove(s) that were used to wipe nose prior to assisting the residents. Employee E6 was not observed changing gloves or sanitizing hands/gloves between wiping nose and handling residents eating utensils or food. Interview on July 11, 2023 at approximately 11:30 a.m. with Dietary Manager E3, revealed that beard guards must be worn in the pantries. It was also revealed, that food distribution {as explained above) was not to the facilities standards. The facility failed to ensure food was served in sanitary conditions in one of four dining rooms. 28 Pa Code 201.18(b)(1)(e)(1) Management 28 Pa Code 211.6(f) Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395974 If continuation sheet Page 5 of 5