Health inspection·July 18, 2025

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interviews with staff, and review of clinical records it was determined the facility failed to obtain laboratory services to meet the needs of one of 38 resident records reviewed (Resident R105). Findings include:Review of Resident R105 clinical records revealed the resident was diagnosed with hypothyroidism (underactive thyroid). Physician orders dated May 14, 2025, instructed a Thyroid stimulating thyroid test (measures the amount of TSH levels in the blood) in five weeks.On July 16, 2025, during an interview with the Unit Manager, Licensed Practical Nurse, Employee E18 stated the doctor has in the progress notes continue to monitor but failed to show the May 2025 order for TSH levels was completed.PA 28 Code 211.12(d)(3)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395282 If continuation sheet Page 2 of 4 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 395282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Center for Rehabilitation & Healthcare 1412 Lansdowne Avenue Darby, PA 19023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Facility failed residents with food preferences.Based on interviews with residents, observations of the food service and a test tray evaluation, interviews with dietary staff, reviews of policies and procedures and reviews of resident council and food committee meeting minutes, it was determined that each resident was not receiving foods and drinks to accommodate their individualized preferences. Appealing food and drink options of similar nutritive value were not being planned and provided on facility menus. (Residents R58, R47, R164, R145, R 207, R208, R220, R77, R117, R196, R64, R194, R144, R219, R86, R50, R234 and R115). Findings include: A review of the facility policy titled resident food committee dated March 2020 revealed that the facility staff were responsible for supporting the food committee established by the residents. The purpose of the residents meeting was to review the menus planned by the Food and Nutrition Department, review special food activities and give the residents a chance to voice concerns about facility food. The policy also said the food service director was responsible for documenting the minutes of the food committee concerns, needs and actions taken to reasonably resolve the food and nutrition issues. The policy indicated that the quality assurance and performance improvement committee would be responsible for overseeing the food committee concerns and accomplishments as part of quality review. A review of the policy titled menu standards dated March 2020 revealed that menus are developed according to standards of menu planning, production and service. The policy indicated that the menu was planned to ensure nutritional adequacy, regulatory compliance, operational efficiencies and to enhance residents' quality of life. The policy indicated that menus are planned to meet national guidelines, to reflect religious, cultural and ethnic needs of the residents based on the advice of the resident council and food committee. A group meeting held with residents at 11:00 a.m., on July 16, 2025 and individual interviews held throughout the days of the survey July 14 to July 18, 2025 revealed that Residents were dissatisfied with the menu planning, foods and fluids being served from the food and nutrition services department. Residents reported that they were not getting foods that they preferred. Residents reported that the menu items planned were not consistently served. The residents reported that the foods lacked variety. There was no variety in the foods provided for a lactose intolerant resident. Residents that were lactose intolerant were asking for a variety of lactose free desserts. The residents were upset that hot dogs and Italian sausage items were taken off the menu. The residents did not like the preparation method and type of meat used for the cheese steak hoagie. The residents reported that the preparation method of the vegetable soup was poor too oily and from a can. The residents were requesting that gravy be served with the chopped steak. The residents were asking that turkey bacon be added to the menu. The residents were reporting that chicken fingers and French fries were being served too often. Residents said that they never get a fried egg and that they were interested. The residents wanted regular coffee. The residents reported that decaffeinated coffee was only offered. Review of the resident council and food committee meeting minutes for the months of April, May and June 2025 revealed that the residents had been complaining about the preparation methods of foods, accuracy of foods and fluids delivered for point of service, entrees selected for the menus not satisfactory and that their individual food preferences were not being honored.Interview with the director of dietary services, Employee E10 at 10:30 a.m., on July 17, 2025, confirmed the on-going (April, May and June, 2025) food and beverage concerns from the residents. The director of dietary also confirmed during this interview that there was a lack of documentation related to the minutes kept for the food committee concerns, needs and actions taken to reasonably resolve the food and nutrition issues.A review of the likes and dislikes listed by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395282 If continuation sheet Page 3 of 4 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 395282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Center for Rehabilitation & Healthcare 1412 Lansdowne Avenue Darby, PA 19023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete dietitians for Residents R47, R50, R145, R77, R207, R208 were not revised to reflect their food preferences. Resident R47 was allergic to eggs however there was no documentation to indicated that food preferences were updated related to egg substitutes or cottage cheese or cream cheese or yogurt for breakfast instead of eggs. Resident R47 wanted regular coffee. There was no documentation to indicate that this resident preferred decaffeinated coffee. Resident R50 was requesting bacon cheeseburgers be added to her diet routinely. There was no documentation to indicate that this resident's food preferences were updated to reflect her needs. Resident R145 was requesting more variety for the menus the resident asked for hot dogs as a menu item. There was no documentation to indicated that this resident's food preferences were updated to reflect her request. Resident R145 also wanted regular coffee. There was no documentation to indicate that Resident R145 preferred a decaffeinated beverage. Resident R77 wanted fresh fruit not canned fruit for her meals. There was no documentation to indicate that the fresh fruit preference was revised as a like for this resident. Resident R207 was ordered a lactose free diet by the physician. This resident was requesting to have a variety of lactose free desserts added to his diet. There was no documentation to indicate that this resident's food preferences were being updated and honored. Resident R208 was requesting that more fresh fruit be added to her diet. There was no documentation to indicate that the resident's food choice was honored. Canned fruit was listed on the menu as being preferred by this resident. Observations during the noon meal service on July 14, 2025 on the fourth floor nursing unit revealed that nursing and dietary staff were not providing all food items listed on the menu for the residents. Residents' meal trays were observed without eight ounces milk; although the preplanned menus indicated that the milk was supposed to be served with lunch. Interview with the director of dietary services, Employee E10 at 12:30 p.m., on July 14, 2025, revealed that the resident who did not get milk do not like it. The director of dietary said that this dislike was recorded in the nutritional care plan. A review of the nutritional care for the residents on the fourth floor nursing unit, revealed that there was no documentation to indicated that all of the residents on the fourth floor preferred not to have milk served at their noon meal services. The lack of updating the nutritional care plans related to beverage choices (eight ounces of milk) for the fourth floor residents that were eating their noon meals on July 14, 2025 was confirmed during interview with the dietitian, Employee E15, at 11:00 a.m., on July 18, 2025. PA 28 Code 201.14(a) Responsibility of licenseePA 28 Code 201.18(b)(1)(3)(e)(1) ManagementPA 28 Code 211.10(a)(b)(c)(d) Resident care policiesPA 28 Code 211.12(d)(3)(5) Nursing services Event ID: Facility ID: 395282 If continuation sheet Page 4 of 4