Inspection·January 17, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, it was determined that the facility failed to maintain an environment that was safe and sanitary in three of 11 rooms observed on the 3rd Floor Unit (rooms [ROOM NUMBER]) Findings include: Observation on the 3rd-floor unit room [ROOM NUMBER] conducted on January 17, 2023, at 10:30 a.m., revealed the following: Scattered dried light brown substance drips on the wall behind the resident's bed; multiple dried brown substance on the floor by the resident's bed, and dried brown substance on the wall near the bathroom door. In addition, the wall behind the resident's bed was observed with an uncovered electrical socket. Observation on the 3rd-floor unit room [ROOM NUMBER] conducted on January 17, 2024, at 10:35 a.m., revealed a dried light brown sticky and a dried dark brown sticky substance by the side of bed A floor, both approximately 1 foot in size. In addition, a light brown dried sticky substance approximately two feet in size was observed on the floor on the foot side of bed B. The sheet on bed A had a dried brown substance stain, and the pillowcase had a dried red substance stain. Observation on the 3rd floor unit room [ROOM NUMBER] bathroom conducted on January 17, 2024, 10:40 a.m., revealed a scattered dried brown substance on the rim of the toilet bowl. Observation conducted on January 17, 2024, at noon in the presence of licensed nurse Employee E3 revealed that the above observations in room [ROOM NUMBER] were still present and in the same condition. Employee E3 reported that the resident in the room had a behavior of throwing food and incontinent products on the floor/walls. Employee E3 also reported that the housekeeping staff already did their morning rounds/cleaning but would come back in the afternoon. Observation conducted on January 17, 2024, at 12:05 noon in the presence of licensed nurse Employee E3 revealed that the above observations in room [ROOM NUMBER] were still present and in the same condition. Employee E3 reported that there was only one resident in the room but had been using both beds. Employee E3 was unaware of the stains on bed A but reported that the sheets should have been changed. While doing the observation with Employee E3, unlicensed staff Employee E4 entered the room and started cleaning bed B. An interview with Employee E4 revealed that the dried substances on the floor had been present since they came in this morning. Observation conducted on January 17, 2024, at 12:10 noon in the presence of licensed nurse Employee E3 revealed that the above observations in room [ROOM NUMBER] bathroom were still present and in (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395078 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 395078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine View Healthcare and Rehabilitation Center 50 North Malin Road Broomall, PA 19008 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)