Health inspection·May 5, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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, observation, and staff interview, it was determined that the facility failed to ensure that a call bell was accessible for one of 25 sampled residents. (Resident 90) Residents Affected - Few Findings include: Clinical record review revealed that Resident 90 had diagnoses that included Parkinson's disease, dementia, chronic obstructive pulmonary disease, and abnormalities of gait and mobility. According to the Minimum Data Set assessment dated [DATE], the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living, including toileting, grooming, and hygiene. Observations on May 2, 2023, at 12:40 p.m., and 1:30 p.m, revealed the resident was in bed and the call bell was under the head of the bed, out of reach. Observations on May 3, 2023, at 12:29 p.m., revealed the resident was out of bed in a wheelchair and the call bell was on the opposite side of the bed, under the head of the bed, and out of reach. In an interview at that time, Resident 90 stated that she did not know where the call bell was. Observations on May 4, 2023, at 9:35 a.m., and 12:10 p.m., revealed Resident 90 was in bed and the call bell was under the head of the bed, out of reach. In an interview on May 5, 2023, at 9:39 a.m., the Administrator confirmed the resident's call bell should have been within reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395402 If continuation sheet Page 2 of 10 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 395402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation it was determined that the facility failed to provide a clean and comfortable environment on two of four nursing units. (Second and Fourth Floors) Findings include: Observation at various times on all days of the survey revealed the following: In room [ROOM NUMBER], the top drawer of the bedside cabinet and dresser were missing. In room [ROOM NUMBER], the molding around the base of the air conditioning unit was missing, and molding at the wall near A bed was coming away from the wall. In room [ROOM NUMBER], there was exposed, unpainted drywall on the right side of the room and the dresser handle was not attached and hanging from one side. In room [ROOM NUMBER], the feeding tube pole had dried liquid, the privacy curtain was falling down from the hooks, the wallpaper under the window was peeled back, the bathroom molding was coming away from the wall, and there were bubbled areas of paint under the sink. In room [ROOM NUMBER], there was a large chunk of tile missing by the entrance and the privacy curtains between B and C beds had brown stains. In the bathroom, the toilet assist bars were loose. In room [ROOM NUMBER], the wallpaper under the windowsill had separated away from the wall and in the bathroom the paint on the wall was bubbled and cracked. In rooms 202, 216, 221, and 228, the air conditioning vents had an accumulation of dirt and debris. In the second floor central bath, the left side shower stall had stool and liquid spatter on the floor. A resident's clothes, a brief, washcloth and towel were on the floor by the toilet. In the second floor pantry, there was a stream of water flowing from the faucet eevn though the handles were in the off position and there was water all over the counter. There was a large area of the wall that had chipped paint and the floor was dirty. The left counter drawer had crumbled packaged crackers, cookies, crumbs, and debris. The microwave had orange spatter and a dry liquid stain. 28 Pa. Code 207.2(a) Administrator's responsibility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395402 If continuation sheet Page 3 of 10 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 395402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the residents' representative(s) of the transfer and the reasons for transfer in writing for five of five sampled residents who were transferred to the hospital. (Residents 43, 52, 61, 78, 132) Findings include: Clinical record review revealed that Resident 43 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and/or the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 52 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and/or the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 61 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and/or the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 78 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and/or the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 132 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and/or the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. In an interview on May 4, 2023, at 1: 21 p.m., the Administrator confirmed that residents and/or residents' representatives were not notified in writing of the transfers to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395402 If continuation sheet Page 4 of 10 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 395402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the Pre-admission Screening and Resident Review (PASARR) or comprehensive assessment for four of 25 sampled residents. (Residents 19, 65, 80, 131) Findings include: Clinical record review revealed that Resident 19 had diagnoses of intellectual disabilities, bipolar disorder, anxiety, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and required extensive assistance from staff. On May 20, 2022, Resident 19 had a Pre-admission Screening and Resident Review (PASARR) Level 1 (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care). According to that assessment, Resident 19 had a positive screen for serious mental illness, intellectual disability, and/or other related condition that identified a need for specialized services in the resident's care plan. These services may include training, treatments, therapies, and related services to help people function as independent as possible. Review of the resident's care plan revealed that the facility did not develop any interventions to address the resident's specialized needs. Clinical record review revealed that Resident 65 had an MDS assessment completed on March 2, 2023. According to the assessment, the resident required dental care and had difficulty communicating. The Care Area Assessment (CAA) summary identified that dental care and communication were problem areas for the resident and should have been included on the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address these care areas. Clinical record review revealed that Resident 80 had an MDS assessment completed on December 1, 2022. According to the assessment the resident was incontinent. The CAA summary of that assessment identified that incontinence was a problem area for the resident and should have been included on the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address Resident 80's incontinence. Clinical record review revealed that Resident 131 had a MDS assessment completed on March 21, 2023. According to the CAA summary, the facility identified that the resident's psychotropic drug and pain medication use were problem areas and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address these care areas. In an interview on May 5, 2023, at 10:09 a.m., the Director of Nursing confirmed that there were no care plan interventions developed to address Resident 19's need for specialized services and the identified care areas for Resident 65, Resident 80, and Resident 131. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395402 If continuation sheet Page 5 of 10 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 395402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, observation, and staff interview it was determined that the facility failed to ensure the oxygen tubing and an oxygen humidification bottle were dated in accordance with facility policy for two of 25 sampled residents. (Residents 88, 90) Residents Affected - Few Findings include: Review of the facility policy entitled, Oxygen: Nasal Cannula, and Oxygen: Aerosol/Tracheostomy Mask/Collar, dated February 1, 2023, revealed that staff was to label and date the oxygen tubing and humidification bottle and place a No Smoking-Oxygen In Use precaution sign on the resident's door. Clinical record review revealed that Resident 88 was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure and had a tracheostomy (a curved plastic tube placed through a small surgical opening in the front of the neck into the windpipe allowing air to flow in and out) in place to provide oxygen. A physician's order dated October 25, 2022, directed staff to administer oxygen at a rate of four liters per minute with cool air mist by tracheostomy collar. Observations on May 2, 2023, at 11:30 a.m., 12:22 p.m., and 1:45 p.m., May 3, 2023, at 10:15 a.m., and 12:30 p.m., and May 4, 2023 at 10:00 a.m., revealed the resident's humidification bottle and tubing were not dated and there was no oxygen in use signage at the resident's door. Clinical record review revealed that Resident 90 was admitted to the facility November 2, 2021, with diagnoses that included chronic obstructive pulmonary disease and anemia. A physician's order dated November 11, 2021, directed staff to administer oxygen at a rate of two liters per minute via nasal cannula (small, flexible tube that contains two open prongs that sit just inside your nostrils and delivers oxygen to your nose). Observations on May 2, 2023, at 12:40 p.m., and 1:30 p.m., May 3, 2023, at 12:29 p.m., and May 4, 2023, at 9:35 a.m., revealed the resident's oxygen tubing was not dated and there was no oxygen in use signage at the resident's door. In an interview on May 5, 2023, at 10:41 a.m., the Director of Nursing confirmed the oxygen tubing and humidification bottle should have been labeled with a date per facility policy. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395402 If continuation sheet Page 6 of 10 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 395402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post Traumatic Stress Disorder for one of 25 sampled residents. (Resident 12) Residents Affected - Few Findings include: Clinical record review revealed that Resident 12 had diagnoses that included Post Traumatic Stress Disorder (PTSD), bipolar disorder and major depressive disorder. There was no assessment or care plan in Resident 12's clinical record that identified the PTSD diagnosis, symptoms and/or triggers related to this diagnosis or resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on May 5, 2023, at 10:19 a.m., the Director of Nursing confirmed that there was no assessment completed or care plan developed to address Resident 12's PTSD diagnosis, symptoms, or triggers. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services. 28 Pa. Code 211.11(e) Resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395402 If continuation sheet Page 7 of 10 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 395402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, policy review, and staff interview, it was determined that the facility failed to adequately monitor residents on psychoactive medications for six of 25 sampled residents. (Residents 19, 80, 106, 125, 129, 131) In addition, the facility failed to document the rationale for the continued use of as needed (PRN) anti-anxiety medications for one of 25 sampled residents. (Resident 19) Residents Affected - Few Findings include: Review of the facility policy entitled, Assessment Grid, dated February 1, 2023, revealed that staff was to assess a resident for abnormal involuntary movements upon a new order for antipsychotic medication and every six months when on an antipsychotic medication. Clinical record review revealed that Resident 19 had diagnoses that included intellectual disabilities, bipolar disorder, major depressive disorder, and anxiety. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and had received an anti-anxiety medication in the last seven days. Review of the current care plan identified that the resident utilized anti-anxiety medications related to anxiety. On February 5, 2023, the physician ordered for staff to administer an anti-anxiety (Ativan) medication every six hours as needed for anxiety. Review of the medication administration record revealed staff had administered the medication 18 times in February 2023, 11 times in March 2023, and 12 times in April 2023. There was no documentation from the physician for the rationale to extend the as needed Ativan beyond 14 days from the original order on February 5, 2023. In addition, since admission the physician ordered that the resident receive an antipsychotic medication (Risperdal). There was no documentation in the clinical record that nursing staff monitored the resident for any abnormal involuntary movements per facility policy. Clinical record review revealed that Resident 80 was admitted to the facility on [DATE], with diagnoses that included dementia, major depressive disorder, and psychosis. Since admission, the physician ordered that the resident receive an antipsychotic medication (Seroquel). There was no documentation in the clinical record that nursing staff monitored the resident for any abnormal involuntary movements per facility policy. Clinical record review revealed that Resident 106 was admitted to the facility July 28, 2022, with diagnoses that included dementia, major depressive disorder, visual hallucinations and drug-induced tremor. Since admission, the physician ordered that the resident receive an antipsychotic medication (risperidone). The ongoing care plan revealed that the resident was to be monitored for adverse side effects related to the use of this medication. There was no documentation in the clinical record that nursing staff monitored the resident for any abnormal involuntary movements per facility policy or adverse side effects. Clinical record review revealed that Resident 125 was admitted to the facility on [DATE], with diagnoses that included dementia, major depressive disorder, and anxiety. Since admission, the physician ordered that the resident receive an antipsychotic medication (Zyprexa). There was no documentation in the clinical record that nursing staff monitored the resident for any abnormal involuntary movements per facility policy. Clinical record review revealed that Resident 129 was admitted to the facility December 31, 2022, with diagnoses that included dementia, Alzheimer's disease, and psychosis. A physician's order dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395402 If continuation sheet Page 8 of 10 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 395402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few January 1, 2023, directed staff to administer an antipsychotic medication (Quetiapine fumarate). The ongoing care plan revealed that the resident was to be monitored for adverse side effects related to the use of this medication. There was no documentation in the clinical record that nursing staff monitored the resident for any abnormal involuntary movements per facility policy or adverse side effects. Clinical record review revealed that Resident 131 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, cocaine abuse and alcohol abuse. Since admission, the physician ordered that the resident recieve an antipsychotic medication (Seroquel). There was no documentation in the clinical record that nursing staff monitored the resident for any abnormal involuntary movements per facility policy. In an interview on May 4, 2023, at 1:15 p.m., the Administrator stated that there was no documentation to support that the aforementioned residents were monitored for abnormal involuntary movements per facility policy. The Administrator also confirmed that there was no documentation in the clinical record of Resident 19 from the physician for the rationale to extend the as needed anti-anxiety medications beyond the 14 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395402 If continuation sheet Page 9 of 10 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 395402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review and observation, it was determined that the facility failed to label and store foods brought to residents by family/visitors per facility policy in one of four unit pantries. (Second floor) Residents Affected - Few Findings include: Review of the facility policy entitled, Food from Outside Sources, dated February 1, 2023, revealed that staff was to label food with the resident's name and date. Any food unconsumed after two days or food past the expiration date on the package would be disposed of by the facility. Observations of the Second floor pantry refrigerator on May 2, 2023 at 12:47 p.m., revealed the following food items labeled as belonging to residents: An open bag of chicken nuggets with no date and the bag was not sealed in the freezer. A gallon bottle of lemonade with no opened date. A container of noodles with no date. 28 Pa. Code 211.6(c) Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395402 If continuation sheet Page 10 of 10