Inspection·June 2, 2025

F 0689 Resident room [ROOM NUMBER]- 125 degrees Fahrenheit Level of Harm - Immediate jeopardy to resident health or safety 3rd floor shower room [ROOM NUMBER] degrees Fahrenheit Residents Affected - Many Interview with Maintenance Employee E3 on May 30, 2025 at 11:12 a.m. after determine water temperatures were confirmed, Employee E3 confirmed the water temperatures were too high in each location, and the temperature should have been under 110 degrees Fahrenheit to comply with Commonwealth of Pennsylvania regulations of a maximum temperature of 110 degrees Fahrenheit. Maintenance Director Employee E3 stated he checks the water temperature daily choosing random rooms on each unit and documenting the temperature in the TELS system (maintenance management system). Further interview with Maintenance Employee E3 revealed the facility had two boilers, one for the domestic water supply the residents use and one for the service areas of the kitchen and laundry. The boiler for the residential water was broken and waiting for a part to complete service. The boiler for the service areas was being used to heat the water for both the service areas and the residential areas while the facility maintenance team were waiting for the necessary part to complete the needed maintenance on the boiler for the residential areas. Observation of the boilers on May 30, 2025 at 11:25 a.m. revealed the water was leaving the boiler at a temperature of 135 degrees Fahrenheit. Interview with Maintenance Employee E3 at the time of the observation revealed that 135 degrees Fahrenheit was the lowest temperature facility maintenance personnel could get the water to coming out of the boiler. Further interview with Maintenance Employee E3 on May 30, 2025 at 11:30 a.m. revealed that he had started at the facility on May 5, 2025 and noticed issues with the water temperatures on his second day of working which was May 7, 2025. Review of facility documentation revealed a Consolidated Service Report dated May 9, 2025 indicating the boiler system needs a new control board. Interview with maintenance Employee E3 on May 30, 2025 at 12:15 p.m. confirmed this is the part the facility maintance staff were waiting to have installed in the residential boiler, and they had been using the service area boiler for all areas of the facility since this time to provide heated water for the residents. Interview with the Nursing Home Administrator on May 30, 2025 at 12:30 p.m. revealed he had been absent from of the facility due to illness and was not made aware of the water temperatures until his return on May 22, 2025 when he signed a Service Repair Proposal for a Diagnostic Board Replacement for the boiler. Interview with the Nursing Home Administrator and Maintenance Employee E3 on May 30, 2025 at approximately 4:45 p.m. revealed the part needed to repair the boiler would not be available until Monday June 2, 2025. The facility was asked to provide water temp logs from May 1, 2025. The facility was unable to provide any documented evidence that water temperatures were being taken, recorded, or monitored to ensure safe temperatures in resident care areas. Observation of the 2nd floor shower room on May 30, 2025 at 10:56 a.m. while taking water temperature, revealed there was no thermometer in the shower room or logs to record the temperature of the water prior to a shower. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395284 If continuation sheet Page 2 of 5 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 395284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Phoenix Center for Rehabilitation and Nursing,the 833 South Main Street Phoenixville, PA 19460 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Interview conducted with Nursing Assistant Employee E4 on May 30, 2025 at 11:30 a.m. revealed, that prior to providing a shower for a resident, staff would spray the water on the resident and ask them if it were comfortable. When asked how staff would ensure a safe water temperature for a resident who was nonverbal or cognitively impaired staff were unable to provide an answer. Interview with Nursing Assistant Employee E5 on May 30, 2025 at 11:35 a.m. revealed prior to providing a shower for a resident, staff would spray the water on the resident and ask them if it were comfortable. When asked how they would ensure a safe water temperature for a resident who was nonverbal or cognitively impaired, Employee E5 was unable to provide an answer. Interview with Nursing Assistant Employee E6 on May 30, 2025 at 11:38 p.m. revealed they would use a thermometer to test the water before providing a shower to the resident and make sure it was under 110 degrees. Nursing Assistant Employee E6 was asked to show this surveyor the thermometer staff would use to determine safe temperature of the shower water, but staff were unable to locate the thermometer. Interview with the Nursing Home Administrator on May 30, 2025 at 12:30 p.m. revealed, staff were expected take water temperature with a thermometer and document the temperature of the water in a log in the shower room. The Nursing Home Administrator was asked multiple times on May 30, 2025 and again on June 2, 2025 for the policy for staff were to follow to ensure safe water temperatures prior to showers and none was able to be provided to the surveyor. Based on the above findings, Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on May 30, 2025, at 1:27 p.m. for failure to ensure safe hot water temperatures were maintained on the nursing unit and proper monitoring was conducted routinely and prior to providing residents with showers. The Nursing Home Administrator was provided with the Immediate Jeopardy template on May 30, 2025 at 1:30 p.m. and an immediate action plan was requested. On May 30, 2025 at 4:32 p.m. the facility provided the following corrective action plan: Shower rooms were placed out of service and thermometers were placed in the shower rooms. [Mechanical Company] on sight on May 30, 2025, to address concerns related to the water system All other rooms in the facility have had hot water temperatures taken and residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hyperthermia are present to include vital signs, skin assessments along with any other relevant assessments related to hyperthermia. Facility staff will be educated on ensuring that water temperatures are checked appropriately before using the water for resident care and it if it out of range to stop use of water immediately and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395284 If continuation sheet Page 3 of 5 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 395284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Phoenix Center for Rehabilitation and Nursing,the 833 South Main Street Phoenixville, PA 19460 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 0689 notify the appropriate parties. Level of Harm - Immediate jeopardy to resident health or safety - Residents Affected - Many Facility water temperatures will be checked every shift by the maintenance director or manger on duty/facility administration to ensure that the temperatures are within appropriate range along with resident interviews to ensure that they are comfortable with the current temperatures. If the water temperature when checked does not meet and maintain the appropriate temperatures the facility will initiate the emergency plan to include closure of the shower rooms and providing residents with bed baths, allowing the water to reach appropriate temperatures before beginning. An Ad Hoc QAPI meeting was held on May 30, 2025 to discuss the events surrounding the facility's failure to ensure that the water temperature in the facility were maintained between 105 and 110 degrees Fahrenheit, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding ensuring that water temperatures are appropriately maintained in the facility, the facility has a plan in place when water temperatures are mot maintained and to ensure that the system responsible for water temperatures has routine maintenance. Interviews were conducted with 15 staff members between May 31, 2025 and June 2, 2025 and Facility staff were able to confirm education was provided on the appropriate water temperature range; to use a thermometer to test the water prior to usage; notify maintenance and/or Nursing Home Administrator if water temperatures are too high and showering was currently suspended. Review of facility documentation of hot water temperatures revealed the facility is currently monitoring the temperature of the hot water. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on June 2, 2025 at 3:58 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 205.63 (c) Plumbing & Piping Systems-Hot Water Outlets 28 Pa. Code 211.10 (d) Resident Care Policies 28 Pa. Code 211.12 (d) (1)(2)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395284 If continuation sheet Page 4 of 5 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 395284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Phoenix Center for Rehabilitation and Nursing,the 833 South Main Street Phoenixville, PA 19460 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 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 Based on observations, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to hot water temperatures which resulted in an Immediate Jeopardy situation. Residents Affected - Few Findings include: Review of the job description for the Nursing Home Administrator revealed the Nursing Home Administrator is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' need in compliance with federal, state and local requirements; establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Observations in the facility revealed that water temperatures were above 110 degrees Fahrenheit on the first, second and third floor. Interview the Maintenance Employee E3 on May 30, 2025 after the observation confirmed the water temperatures were above 110 degrees. Further interview with Maintenance Employee E3 on May 30, 2025 revealed that one of the boilers was in need of repair and the boiler for the service areas of the facility was being used for the residential areas and the water was leaving the boiler at 135 degrees and could not be lowered further. There was no documented evidence provided to the surveyor that the water temperatures were being monitored and the Nursing Home Administrator was made aware of the issue when he returned from a leave of absence on May 22, 2025 and there were no new interventions put into place knowing that the water was hot and could not be rectified until a new part was installed on the boiler designated for residential use. This failure placed residents at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation. Based on the deficiencies identified in this report the NHA failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situations. Refer to F689 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395284 If continuation sheet Page 5 of 5