Health inspection·February 8, 2025

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with residents and staff, review of facility policy, and facility documentation, it was determined the facility failed to ensure comfortable air temperature levels were provided on two of two nursing units (Second and Third Floor), placing 16 residents at risk for developing hypothermia (condition of having a lower body temperature than normal body temperature). This failure resulted in an Immediate Jeopardy situation with air temperatures ranging between 59 degrees Fahrenheit and 70 degrees Fahrenheit in two of two nursing units. (Second and Third Floor). Findings include: Review of the undated facility policy titled Facility Temperature Policy and Procedures revealed The facility will maintain indoor air temperatures within the required range to promote the health, safety, and comfort of residents and staff. The facility will monitor, document, and respond to temperature deviations in a timely manner to prevent adverse effects on resident well-being. It further under procedures outlines, Resident care areas (e.g., rooms, hallways, common areas) must be maintained between 71°F and 81°F (Fahrenheit) per federal regulations. Observations conducted on February 7, 2025, at 10:09 a.m. with the Maintenance Assistant, Employee E3 revealed the following air temperatures: 2nd floor nursing unit East hallway- 65.3 of degrees Fahrenheit -room [ROOM NUMBER]-64.9 of degrees Fahrenheit -room [ROOM NUMBER]-62.2 of degrees Fahrenheit -room [ROOM NUMBER]- 59.0 of degrees Fahrenheit 2nd floor nursing unit [NAME] hallway- 63.8 of degrees Fahrenheit -room [ROOM NUMBER]-64.0 of degrees Fahrenheit -room [ROOM NUMBER]-61.8 of degrees Fahrenheit -room [ROOM NUMBER]-59.0 of degrees Fahrenheit 2nd Floor nursing unit North hallway- 65.8 of degrees Fahrenheit Page 1 of 9 396115 396115 02/08/2025 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0584 -room [ROOM NUMBER]-63.8 of degrees Fahrenheit Level of Harm - Immediate jeopardy to resident health or safety -room [ROOM NUMBER]-65.4 of degrees Fahrenheit Residents Affected - Some 3rd floor nursing station- 69.8 of degrees Fahrenheit -room [ROOM NUMBER]-66.9 of degrees Fahrenheit -3rd Floor dining area 59.3 of degrees Fahrenheit -3rd East hallway 66.9 of degrees Fahrenheit -room [ROOM NUMBER]-61.7 of degrees Fahrenheit -room [ROOM NUMBER]-59.3 of degrees Fahrenheit 3rd floor nursing unit [NAME] hallway- 66.2 of degrees Fahrenheit -room [ROOM NUMBER]-65.4 of degrees Fahrenheit -room [ROOM NUMBER]-60.2 of degrees Fahrenheit 3rd nursing unit North hallway -69 of degrees Fahrenheit -room [ROOM NUMBER]-62.9 of degrees Fahrenheit -room [ROOM NUMBER]-61.5 of degrees Fahrenheit On February 7, 2025, at approximately 10:25 a.m. an interview with Resident R3 who was observed wearing sweatshirt, and coat, reported yesterday I got up and it was so cold, facility has no heat no hot water. On February 7, 2025, at 10:28 a.m., an interview was conducted with Nurse Aide, Employee E9, who reported, It's cold today. Nurse Aide, Employee E9 noted that it had not been this cold the previous week. On February 7, 2025, at approximately 10:31 a.m. an interview was conducted with Resident R4 who was observed wearing a hat and reported, it's cold in this room referring to room [ROOM NUMBER]. On February 7, 2025, at approximately 10:33 a.m. an interview with Resident R5 reported it's cold. On February 7, 2025, at 10:45 a.m. an interview with License Nurse, Employee E8 revealed today was the first day that it has been this cold in the building. On February 7, 2025, at 10:54 a.m. an interview was conducted with the Maintenance Director, Employee E6. During the interview, Employee E6 reported the facility experienced issues last week due to water pipes breaking outside. As a result, sand and debris entered the toilets and pipes, affecting their functionality. The heat is working but it goes in and out. The last measurement of the heat temperatures was yesterday. 396115 Page 2 of 9 396115 02/08/2025 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On February 7, 2025, at 11:02 a.m., an interview was held with Resident R7 reported it's cold Resident R7 was covered with a blanket, dressed in a winter jacket, sweatshirt and hat. On February 7, 2025, at 11:05 a.m., an interview was conducted with the Nursing Home Administrator, Employee E1, on the second nursing unit. Employee E1 reported the thermometer gun used by the Maintenance Assistant was broken and their own thermometer gun was displaying fluctuating temperatures around 70°F. On February 7, 2025, at 11:12 a.m. Nursing Home Administrator recaptured air temperature levels using a different thermometer. Air temperature recordings were as follows: -room [ROOM NUMBER]- registered 68 of degrees Fahrenheit -2nd floor dining room - registered 65 of degrees Fahrenheit -2nd floor east hallway - 69.2 of degrees Fahrenheit -room [ROOM NUMBER]- registered 65 of degrees Fahrenheit -room [ROOM NUMBER]-69 of degrees Fahrenheit -room [ROOM NUMBER]- 68 of degrees Fahrenheit -2nd floor North hallway - 68 of degrees Fahrenheit -1st floor hallway by the elevators- 69 of degrees Fahrenheit On February 7, 2025 at approximately 11:20 a.m. observation of the second-floor supply room failed to reveal additional warm blankets. On February 7, 2025 at approximately 11:28 a.m. observations conducted of the the third-floor supply room failed to reveal additional warm blankets. On February 7, 2025, at 11:35 a.m., an observation was conducted with the Housekeeping Director, Employee E7, which revealed that only one warm blanket remained on the rack in the laundry room. During interview with the Housekeeping Director, Employee E7 at the time of the observation Employee E7 was asked if facility has any additional blankets? Employee E7 stated that he just returned from placing additional blankets to the 2nd and 3rd nursing units' supply room. Observation conducted of the 2nd and 3rd nursing units' supply room on February 7, 2025 at 11:40 p.m. in the company of the Nursing Home Administrator, Employee E1 revealed that the second-floor supply room had no warm blankets while the third-floor supply room contained one additional warm blanket along with a few additional regular thin blankets. Interview on February 7, 2025, at 11:59 a.m., an interview with Commercial Contractor, Employee E10, revealed there was an issue with the air handler; the supply fan had moved off the shaft and was rubbing against the housing. Due to this malfunction, they recommended shutting it off the system on Wednesday, February 5, 2025, to prevent further damage, and the facility was aware of this action. Continued interview with Commercial Contractor, Employee E10 stated that he/she returned today to 396115 Page 3 of 9 396115 02/08/2025 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some assess the issue further and provide an exact repair quote. Commercial Contractor, Employee E10 was in the process of preparing a quote, after which the necessary parts will need to be ordered and repairs scheduled, pending approval. The facility instructed the contractor to turn the air handler back on. On February 7, 2025, at 12:28 p.m., an interview was conducted with Nursing Aide, Employee E4, who reported feeling cold. The facility has been providing blankets to residents who are experiencing cold temperatures. On February 7, 2025, at 12:32 p.m., an interview was conducted with Resident R8 who reported it's freezing here. Based on the above findings Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on February 7, 2025, at 12:45 p.m. for failure to maintain comfortable air temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit on two of two nursing floors which posed a health and/or safety risk to 16 residents on the Second and Third Floor nursing units through the loss of body heat. The Nursing Home Administrator was provided with the Immediate Jeopardy template on February 7, 2025, at 12:45 p.m. and an immediate action plan was requested. The following action plan was received and accepted on February 7, 2024, at 5:30 p.m. -On February 7, 2025, the facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that facility air temperatures were maintained between 71- and 81- degrees Fahrenheit. -Residents that resided in affected rooms were offered a room move and declined. They were informed that if they were unconformable and would like to move rooms at any time to inform facility staff. -[Plumbing Company] on site on February 7, 2025, to address concerns related to the heating unit. Additional blankets were purchased and provided to residents. -Warming liquid hydration stations were placed in resident common areas by culinary staff on February 7, 2025. -All 16 residents identified were assessed by nursing staff to ensure that there have been no undesired outcomes related to hypothermia and that no signs and symptoms of hypothermia were present to the central heating system being temporarily inoperable to include vital signs, skin assessment and any other pertinent assessments. -All other rooms in the facility will have temperatures taken and residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hypothermia are present to include vital signs, skin assessments along with any other relevant assessment related to hypothermia. -Facility staff will be educated on ensuring residents remain warm and to ensure that residents are assessed frequently to ensure that no signs of symptoms of hypothermia are present. -Facility temperature will be checked every shift by the manager on duty and facility administration to ensure that they are within appropriate range along with resident interview to ensure that they 396115 Page 4 of 9 396115 02/08/2025 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0584 are comfortable with the current temperatures. Level of Harm - Immediate jeopardy to resident health or safety -If the facility rooms affected does not meet and maintain the appropriate temperatures facility will initiate the emergency plan to include closure of the effected rooms and mandate movement of resident to functioning rooms. Residents Affected - Some An Ad Hoc QAPI Meeting was held on February 7, 2025 to discuss the events surrounding the facility's failure to ensure temperatures in the facility were maintained between 71- and 81- degrees Fahrenheit, to identify the root cause, and to initiate improvement to the facility's processes and procedures regarding ensuring temperature levels are appropriately maintained in the facility, the facility has a plan in place when temperatures are not maintained and to ensure that the central heating system has routine maintenance. -The PA Healthcare Coalition was notified via phone with a voice message left on February 7, 2025. On February 7, 2025, at 3:47 p.m., an interview was conducted with Heating and Air Contractor, Employee E11, reported that the heating issue had been resolved. Temperatures in the hallways and rooms were increasing. Observations on February 8, 2025, at 12:45 p.m. revealed the Second-floor nursing unit-maintained temperatures between 71- and 81- degrees Fahrenheit. The third nursing unit continued to have rooms with 7 rooms were below 71 degrees Fahrenheit. Facility brought portable space heater (safe) to maintain air temperature levels between 71- and 81- degrees Fahrenheit. The facility provided education to all staff on assessing residents for signs and symptoms of hypothermia. Staff were instructed to ensure residents remained warm by providing blankets, conducting vital sign checks every shift, and offering warm beverages as needed. The vital signs auditing was reviewed and residents were not exhibiting signs and symptoms of hypothermia. On February 8, 2025, at 5:30 p.m., the Immediate Jeopardy was lifted. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 28 Pa. Code 204.19 Plumbing, heating ventilation and air conditioning and electric 396115 Page 5 of 9 396115 02/08/2025 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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, facility documentation and interviews with residents and staff, it was determined the Nursing Home Administrator failed to effectively manage the facility related to the failure to maintain air temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit in 16 resident rooms, dining rooms and nursing units for two out of two nursing units. (Second and Third Floor) The failure to maintain comfortable and safe air temperatures for a total of 16 residents residing in rooms 202, 206, 211, 217, 224, 225, 228, 234, 238, 305, 306, 316, 325, 331, and 333 resulted in an Immediate Jeopardy situation. (Second and Third Floor) Residents Affected - Few Findings include: Review of the job description for the Nursing Home Administrator revealed that the Administrator was responsible to operate the facility in accordance with the established policies and procedures of the governing body in compliance with federal, state and local regulations. Establish systems to enforce the facility policies and procedures. Establish operating procedures for physician responsibilities. Act as liaison to the governing body for the medication, nursing and other professional staff and all facility departments. Prepare all reports required by the governing body. Supervise all departments supervisors and administrative staff. Supervise the recruitment, employment, performance evaluations, promotion, and discharge of all staff. Assume responsibility with department supervisors to implement effective policies and assure adequate staffing to meet facility needs. Be responsible to all financial transactions. Ensure that all necessary supplies are purchased and available. Develop relationship with community agencies providing services of benefit to the facility. Develop one to one relationship with residents and family. Arrange with appropriate state and legal agencies for the guardianship of those residents in need. Arbitrate complaints and disputes concerning residents, family and personnel. Observations conducted on February 7, 2025, at 10:09 a.m. with the Maintenance Assistant, Employee E3 revealed the following air temperatures: 2nd floor nursing unit East hallway- 65.3 of degrees Fahrenheit -room [ROOM NUMBER]-64.9 of degrees Fahrenheit -room [ROOM NUMBER]-62.2 of degrees Fahrenheit -room [ROOM NUMBER]- 59.0 of degrees Fahrenheit 2nd floor nursing unit [NAME] hallway- 63.8 of degrees Fahrenheit -room [ROOM NUMBER]-64.0 of degrees Fahrenheit -room [ROOM NUMBER]-61.8 of degrees Fahrenheit -room [ROOM NUMBER]-59.0 of degrees Fahrenheit 2nd Floor nursing unit North hallway- 65.8 of degrees Fahrenheit 396115 Page 6 of 9 396115 02/08/2025 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0835 -room [ROOM NUMBER]-63.8 of degrees Fahrenheit Level of Harm - Minimal harm or potential for actual harm -room [ROOM NUMBER]-65.4 of degrees Fahrenheit -room [ROOM NUMBER]-66.9 of degrees Fahrenheit Residents Affected - Few 3rd floor nursing station- 69.8 of degrees Fahrenheit -3rd Floor dining area 59.3 of degrees Fahrenheit -3rd East hallway 66.9 of degrees Fahrenheit -room [ROOM NUMBER]-61.7 of degrees Fahrenheit -room [ROOM NUMBER]-59.3 of degrees Fahrenheit 3rd floor nursing unit [NAME] hallway- 66.2 of degrees Fahrenheit -room [ROOM NUMBER]-65.4 of degrees Fahrenheit -room [ROOM NUMBER]-60.2 of degrees Fahrenheit 3rd nursing unit North hallway -69 of degrees Fahrenheit -room [ROOM NUMBER]-62.9 of degrees Fahrenheit -room [ROOM NUMBER]-61.5 of degrees Fahrenheit On February 7, 2025, at approximately 10:25 a.m. an interview with Resident R3 who was observed wearing sweatshirt, and coat, reported yesterday I got up and it was so cold, facility has no heat no hot water. On February 7, 2025, at 10:28 a.m., an interview was conducted with Nurse Aide, Employee E9, who reported, It's cold today. Nurse Aide, Employee E9 noted that it had not been this cold the previous week. On February 7, 2025, at approximately 10:31 a.m. an interview was conducted with Resident R4 who was observed wearing a hat and reported, it's cold in this room referring to room [ROOM NUMBER]. On February 7, 2025, at approximately 10:33 a.m. an interview with Resident R5 reported it's cold. On February 7, 2025, at 10:45 a.m. an interview with License Nurse, Employee E8 revealed today was the first day that it has been this cold in the building. On February 7, 2025, at 10:54 a.m. an interview was conducted with the Maintenance Director, Employee E6. During the interview, Employee E6 reported the facility experienced issues last week due to water pipes breaking outside. As a result, sand and debris entered the toilets and pipes, affecting their functionality. The heat is working but it goes in and out. The last measurement of the heat temperatures was yesterday. 396115 Page 7 of 9 396115 02/08/2025 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On February 7, 2025, at 11:02 a.m., an interview was held with Resident R7 reported it's cold Resident R7 was covered with a blanket, dressed in a winter jacket, sweatshirt and hat. On February 7, 2025, at 11:05 a.m., an interview was conducted with the Nursing Home Administrator, Employee E1, on the second nursing unit. Employee E1 reported the thermometer gun used by the Maintenance Assistant was broken and their own thermometer gun was displaying fluctuating temperatures around 70°F. On February 7, 2025, at 11:12 a.m. Nursing Home Administrator recaptured air temperature levels using a different thermometer. Air temperature recordings were as follows: -room [ROOM NUMBER]- registered 68 of degrees Fahrenheit -2nd floor dining room - registered 65 of degrees Fahrenheit -2nd floor east hallway - 69.2 of degrees Fahrenheit -room [ROOM NUMBER]- registered 65 of degrees Fahrenheit -room [ROOM NUMBER]-69 of degrees Fahrenheit -room [ROOM NUMBER]- 68 of degrees Fahrenheit -2nd floor North hallway - 68 of degrees Fahrenheit -1st floor hallway by the elevators- 69 of degrees Fahrenheit On February 7, 2025 at approximately 11:20 a.m. observation of the second-floor supply room failed to reveal additional warm blankets. On February 7, 2025 at approximately 11:28 a.m. observations conducted of the the third-floor supply room failed to reveal additional warm blankets. On February 7, 2025, at 11:35 a.m., an observation was conducted with the Housekeeping Director, Employee E7, which revealed that only one warm blanket remained on the rack in the laundry room. During interview with the Housekeeping Director, Employee E7 at the time of the observation Employee E7 was asked if facility has any additional blankets? Employee E7 stated that he just returned from placing additional blankets to the 2nd and 3rd nursing units' supply room. Observation conducted of the 2nd and 3rd nursing units' supply room on February 7, 2025 at 11:40 p.m. in the company of the Nursing Home Administrator, Employee E1 revealed that the second-floor supply room had no warm blankets while the third-floor supply room contained one additional warm blanket along with a few additional regular thin blankets. Interview on February 7, 2025, at 11:59 a.m., an interview with Commercial Contractor, Employee E10, revealed there was an issue with the air handler; the supply fan had moved off the shaft and was rubbing against the housing. Due to this malfunction, they recommended shutting it off the system on Wednesday, February 5, 2025, to prevent further damage, and the facility was aware of this action. Continued interview with Commercial Contractor, Employee E10 stated that he/she returned today to 396115 Page 8 of 9 396115 02/08/2025 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assess the issue further and provide an exact repair quote. Commercial Contractor, Employee E10 was in the process of preparing a quote, after which the necessary parts will need to be ordered and repairs scheduled, pending approval. The facility instructed the contractor to turn the air handler back on. On February 7, 2025, at 12:28 p.m., an interview was conducted with Nursing Aide, Employee E4, who reported feeling cold. The facility has been providing blankets to residents who are experiencing cold temperatures. On February 7, 2025, at 12:32 p.m., an interview was conducted with Resident R8 who reported it's freezing here. Based on the above findings an Immediate Jeopardy was identified for failure to provide safe and comfortable air temperatures for residents living on the Second and Third nursing units. The facility's failure to furnish the necessary maintenance services to ensure that safe and comfortable temperature levels were maintained in resident rooms and hallways posed a safety risk with the loss of body heat for 16 residents identified. Based on the deficiencies identified in this report, the Nursing Home Administrator failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situation. 28 Pa. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 204.19 Plumbing, heating ventilation and air conditioning and electric 396115 Page 9 of 9