Health inspection·December 3, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility documentation, clinical record review, observations and staff interviews, the facility failed to ensure that a mechanical lift was used in a safely manner to prevent accidents for one of six records reviewed. (Resident CL1)Findings include: Review of facility provided documentation titled, Invacare User Manual dated 2013, indicated that when lifting a resident or moving a resident while they are in the sling, the legs of the lift must be in the fully open position for maximum stability and safety. Review of clinical records for Resident CL1 revealed that the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness, and difficulty walking. Continued review revealed that the resident required two people to assist with transfers via Hoyer lift (mechanical lift utilize to transfer a resident from one surface to another). Review of nursing notes for Resident CL1, dated October 31, 2025, revealed that a nurse aide reported that during the Hoyer lift transfer from chair to bed, Resident CL1 was lowered to the floor due to the Hoyer tilted over to the side over one of the nurse aids. Review of facility investigation dated October 31, 2025, revealed that Resident CL1 was found laying on the floor on his back with the Hoyer pad under him, on the right side of the bed with two NA in the room. Continued review revealed that during the transfer from chair to bed, the Hoyer tilted over to the side over one of the Nurse aids and the patient had to be lowered to the floor. Interview conducted on December 3, 2025, at 12:15 p.m. with Nurse Aide, Employee E3, revealed that when transferring the resident from chair into bed via the Hoyer lift, the device tilted on to Employee E3, which resulted in the Resident CL1 being lowered to the ground. Continued interview revealed that the Hoyer lift legs were not widened at the time of transfer. Follow-up interview and observations conducted on December 3, 2025, at 12:30 p.m. with Employee E3, the Nurse aide demonstrated the Hoyer lift transfer and confirmed that the Hoyer lift was operated without properly widening the legs, which resulted in the lift tipping. Interview conducted on December 3, 2025, at 1:00 p.m. with facility Administrator and Director of Nursing, confirmed that the Hoyer lift legs must be widened upon transfer.28 Pa. Code 211.10 (d) Resident Care Policies. 28 Pa. Code 211.12 (d)(5) Nursing Services. Page 1 of 2 396115 396115 12/03/2025 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of resident records, facility policy, and staff interviews, it was determined that the facility failed to maintain complete and accurate clinical records for one of six residents reviewed. (Resident CL1)Findings include: Review of facility policy titled, Repositioning revised May 2013, indicated that repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Continued review revealed that the following information should be recorded in the residents medical record: the position in which the resident was placed; the name and title of the individual who gave the care; any problems or complaints made by the resident related to the procedure; if the resident refused the care and the reasons why; and the signature and title of the person recording the data. Review of Resident CL1's clinical records titled, Encore Wound Care dated October 23, 2025, indicated that the resident must be repositioned per facility protocol. Further review of Resident Cl1's clinical records failed to reveal documented evidence of a turning and repositioning program for Resident CL1, including a continuous consistent program for changing the resident's position and realigning the body. Interview with the facility Administrator and Director of Nursing conducted on December 3, 2025, at approximately 2:00 p.m. confirmed that there is no documented evidence indicating that Resident CL1 was repositioned or turned at least every two-hour repositioning schedule, per policy. 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(iv)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 396115 Page 2 of 2