Health inspection·February 4, 2026

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy and interview with staff it was determined that the facility failed to ensure that pain medications were administered according to physician's order for one of two residents reviewed (Resident R1)Review of facility policy on Administering Pain Medications revealed that under section Purpose the purpose of this procedure is to provide guidance for assessing the residence level of pain prior to administering analgesic pain medication under section General Guidelines #1. The pain management program is based on a facility-wide commitment to resident comfort #2. Pain management is defined as the process of alleviating the residence pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals #7. The pain assessment consists of gathering both subjective and objective data. Under Equipment and Supplies the following equipment and supplies will be necessary when performing this procedure: #1. Standardized pain assessment tools as indicated per facility protocol for example a 5-point or 10-point pain intensity scale with word modifiers under section step in the procedure Further review of the 'Administering Pain Medication policy revealed that the numeric pain assessment scale did not specify the scale numbers for mild, moderate or severe pain. Interview with a Director of Nursing, Employee E2 conducted on February 3, 2026, at 10:32AM revealed that the facility's pain scale was as follows 1-3 mild pain, 4-6 moderate pain, 7 -10 severe pain.Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of but not limited to Back Pain.Further review of resident R1's clinical record revealed physicians order for Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe pain and Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Mild Pain Not to exceed 3000mg/24hrFurther review of Resident R1's clinical record revealed that there was no physician's order for pain medication for moderate pain. Review of Resident R1's medication administration record for January 2026 revealed that following:On January 2, 2026, at 10:46PM, Resident R1 had a pain scale of 5 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 3, 2026, at 05:04 PM, Resident R1 had a pain scale of 5 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 8, 2026, at 10:29AM, Resident R1 was given Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Mild Pain Not to exceed 3000mg/24hr. Pain scale for the day shift of January 8, 2026, was coded 0 for pain.On January 9, 2026, at 01:09 PM, Resident R1 had a pain scale of 4 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 14, 2026, at 04:58 AM, Resident R1 had a pain scale of 0 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 16, 2026, at 01:31PM, Resident R1 had a pain scale of 4 and was given Morphine Sulfate Oral Tablet 15 MG Residents Affected - Few Page 1 of 3 396115 396115 02/04/2026 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 17, 2026, at 08:11AM, Resident R1 had a pain scale of 0 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 18, 2026, at 11:00AM, Resident R1 had a pain scale of 5 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 20, 2026, at 02:11PM, Resident R1 had a pain scale of 4 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 21, 2026, at 04:17PM, Resident R1 had a pain scale of 4 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe pain.Interview with Employee E2 conducted on February 4, 2026, at 11:23 AM confirmed that Morphine was administered to Resident R1 for pain scale of less than the indicated severe pain.Further, interview with facility administrator Employee E1 and Director of Nursing Employee E2 confirmed that there was no pain management for moderate pain. 28 Pa. Code 211.10(c) Resident care28 Pa. Code 211.12(d)(1) Nursing services 396115 Page 2 of 3 396115 02/04/2026 Wyndmoor Hills Rehabilitation and Nursing Center 8601 Stenton Avenue Wyndmoor, PA 19038

F 0697 Provide safe, appropriate pain management 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 review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to provide pain management for residents in severe pain for one of two residents reviewed (Resident R1).Review of facility policy on Administering Pain Medications revealed that under section Purpose the purpose of this procedure is to provide guidance for assessing the residence level of pain prior to administering analgesic pain medication under section General Guidelines #1. The pain management program is based on a facility-wide commitment to resident comfort #2. Pain management is defined as the process of alleviating the residence pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals #7. The pain assessment consists of gathering both subjective and objective data. Under Equipment and Supplies the following equipment and supplies will be necessary when performing this procedure: #1. Standardized pain assessment tools as indicated per facility protocol for example a 5-point or 10-point pain intensity scale with word modifiers under section step in the procedure.Further review of the 'Administering Pain Medication policy revealed that the numeric pain assessment scale did not specify the scale numbers for mild, moderate or severe pain. Interview with a Director of Nursing, Employee E2 conducted on February 3, 2026, at 10:32AM revealed that the facility's pain scale was as follows 1-3 mild pain, 4-6 moderate pain, 7 -10 severe pain.Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of but not limited to Back Pain.Further review of resident R1's clinical record revealed physicians order for Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe pain.Further review of Resident R1's clinical record revealed an order for Pain Assessment/Pain Monitor (Able to communicate - Do you have pain? If Denies -Stop here. If Yes - Indicate Pain score 0-10, Offer a nonpharmacological intervention: 1. Repositioning/Turning, 2. Distraction, 3. Massage, 4. Hot/Cold Compress, 5. Emotional Support, 6. Quiet Environment, 7. Other, 8. Not Applicable every shift for Pain Monitoring ordered on December 22, 2025.Review of Resident R1's medication administration record for January 2026 revealed that on January 5, 2026, during the 3-11 shift, Resident R1 had a pain scale of 7. Further review of Resident R1's Medication administration record revealed that Resident R1 did not receive Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe pain.Further review of Resident R1 clinical record revealed no documented evidence that Resident R1 received any pain management technique to alleviate his pain.Interview with Employee E2 conducted on February 4, 2026, at 11:23 AM confirmed that Morphine was not administered to Resident R1 on January 5, 2026, during the 3-11 shift when he had a pain scale of 7. 28 Pa. Code 211.10(a) Resident care Residents Affected - Few 396115 Page 3 of 3