Inspection·June 1, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure that a safe, clean, and comfortable environment was maintained on three of three nursing units. (Rehabilitation, First and Second floor) Findings include: Observations on the rehabilitation nursing unit on May 30, 2023, at 11:26 a.m., through May 31, 2023, at 10:40 a.m., revealed the following: In room [ROOM NUMBER], there were heavily marred walls and peeling wallpaper by the door. In room [ROOM NUMBER], the bathroom floor was heavily stained, the baseboard behind the toilet was missing, the toilet was loose, and the bathroom had a strong pervasive urine odor. In room [ROOM NUMBER], there was a brown stained ceiling tile over the television. In rooms 14, 15, 23, 27, and 30 the walls were heavily marred and scratched. During tour of the first floor nursing unit on May 30, 2023, at 10:00 a.m. through May 31, 2023, at 1:30 p.m. the following observations were made: In room [ROOM NUMBER], a dried brown substance was observed around the base of the toilet and there were dirty gowns, towels, and wash cloths piled up on the trash can in the bathroom. In room [ROOM NUMBER], the wall by the window was heavily marred and scratched and the room had a strong pervasive urine odor. Observations on the second floor nursing unit on May 31, 2023, at 12:00 p.m. revealed that in room [ROOM NUMBER] there were two brown stained ceiling tiles over the window bed. 28 Pa. Code 207.2(a) Administrator responsibility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 2 of 11 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 395796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomeryville Skilled Nursing and Rehabilitati 640 Bethlehem Pike Montgomeryville, PA 18936 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 - Some 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 comprehensive assessment for six of 25 sampled residents. (Residents 50, 65, 97, 114, 115, 116) Findings include:. Clinical record review revealed that Resident 50 had a diagnosis of end-stage kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], identified that the resident received hospice services and a care plan should have been developed to address the hospice services. Review of the care plan revealed that the facility did not develop interventions to address hospice care. Clinical record review revealed that Resident 65 had a diagnosis that included dementia. Review of the MDS assessment dated [DATE], identified that the resident received hospice services and a care plan should have been included on the resident's care plan. Review of the care plan revealed that the facility did not develop interventions to address the resident's hospice care. Clinical record review revealed that Resident 97 had a MDS assessment that was completed on April 21, 2023. According to the assessment, the resident had pain almost constantly that caused limitation in day-to-day activities. According to the Care Area Assessment (CAA) summary from that assessment, pain was a problem for the resident, and should have been included on the care plan. Review of the care plan revealed that the facility did not develop interventions to address the resident's pain Clinical record review revealed that Resident 114 had diagnoses that included Alzheimer's disease. Review of the MDS assessment dated [DATE], identified that the resident received psychotropic medications. According to the CAA summary assessment the facility identified the resident's psychotropic medications use was a problem and should have been included on the care plan. Review of the care plan revealed that the facility did not develop a care plan with interventions to address the need for psychotropic medications. Clinical record review revealed that Resident 115 had diagnoses that included spinal stenosis, (a condition where the space inside your spine becomes too narrow) low back pain, and chronic kidney disease. Review of the MDS assessment dated [DATE], identified that the resident had pain, and was incontinent of bowel and bladder. The CAA summary assessment identified that pain, and incontinence was a problem 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 116 had a MDS assessment completed on February 9, 2023. According to the assessment the resident was incontinent of bladder. According to the CAA summary from that assessment, the facility identified that incontinence was a problem 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 this care area. In an interview conducted on June 1, 2023, at 10:45 a.m., the Director of Nursing confirmed that there was no care plan developed with interventions to address the residents' needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 3 of 11 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 395796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomeryville Skilled Nursing and Rehabilitati 640 Bethlehem Pike Montgomeryville, PA 18936 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 CFR 483.21(b)(1) Comprehensive Care Plans. Level of Harm - Minimal harm or potential for actual harm Previously cited 07/14/2022 28 Pa. Code 211.11(d) Resident care plan. Residents Affected - Some 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 4 of 11 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 395796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomeryville Skilled Nursing and Rehabilitati 640 Bethlehem Pike Montgomeryville, PA 18936 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, staff and resident interview, it was determined that the facility failed to consistently provide treatments for a pressure ulcer for one of 25 sampled residents. (Resident 116) Residents Affected - Few Findings include: Clinical record review revealed that Resident 116 was admitted to the facility on [DATE], with diagnoses that included a pressure ulcer and anemia. On February 2, 2023, a nurse noted that the resident had a Stage II pressure ulcer to her coccyx and the physician ordered for staff to provide wound care and change the dressing daily. Review of the current care plan revealed that the resident had a pressure ulcer and that staff were to provide treatments as ordered. In an interview on May 31, 2023, at 11:20 a.m., Resident 116 stated that staff do not always provide wound care as ordered. Review of the treatment administration records for February through May 2023, revealed that treatments were not provided as ordered on February 4, 5, 10, and 14, March 2 and 16, April 3 and 20, and May 2, 2023. In an interview on June 1, 2023, at 11:30 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident 116's wound treatments were completed as ordered. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 5 of 11 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 395796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomeryville Skilled Nursing and Rehabilitati 640 Bethlehem Pike Montgomeryville, PA 18936 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide services to increase range of motion and/or prevent further decrease in range of motion for one of nine sampled residents with impairment. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included diabetes mellitus and difficulty walking. The Minimum Data Set assessment dated [DATE], indicated that the resident was oriented and needed some staff assistance for activities of daily living, such as transferring and walking. A physical therapy Discharge summary dated [DATE], noted that the resident was evaluated for transferring positions, walking, and functional mobility. The discharge recommendations were for Resident 3 to have a home exercise program and to be referred for a restorative nursing program. On June 1, 2023, at 9:15 a.m. Resident 3 stated that staff did not assist her with restorative exercises. There was a lack of documentation to support that the physical therapist's recommendation for a restorative nursing program was implemented for Resident 3. During an interview on June 1, 2023, the Director of Therapy confirmed that Resident 3's restorative nursing program had not been implemented. CFR 483.25(c)(2) Mobility. Previously cited 7/14/22 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 6 of 11 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 395796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomeryville Skilled Nursing and Rehabilitati 640 Bethlehem Pike Montgomeryville, PA 18936 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **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 assess bladder incontinence for two of 25 sampled residents (Residents 116, 119) Findings include: Review of the facility policy entitled, Continence Management, last reviewed February 14, 2023, revealed that facility staff was to complete a urinary incontinence assessment upon admission or re-admission and with a change in condition or change in continence status. Clinical record review revealed that Resident 116 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection and anemia. According to the Minimum Data Set (MDS) assessment, dated April 6, 2023, the resident was easily understood, and needed extensive assistance from staff for toileting. The assessment further indicated that the resident was frequently incontinent of urine and was not on a toileting program. There was no documentation in the clinical record to support that the resident's urinary incontinence was assessed by the facility to determine if normal bladder function could be restored. According to nurse aide records, the resident had been frequently incontinent since admission to the facility. Clinical record review revealed that Resident 119 was admitted to the facility on [DATE], with diagnoses that included obstructive uropathy. On May 8, 2022, the physician ordered for the resident to use an urniary catheter. Review of the nursing notes revealed that the catheter was removed on April 13, 2023. According to the MDS assessment dated [DATE], the resident was easily understood, and needed extensive assistance from staff for toileting. The assessment further indicated that the resident was frequently incontinent of urine and was not on a toileting program. There was no documentation in the clinical record to support that the resident's urinary incontinence was assessed to determine if normal bladder function could be restored after her indwelling urinary catheter was removed. In an interview on June 1, 2023, at 10:37 a.m., the Director of Nursing stated that Resident 116's and 119's urinary incontinence had not been assessed per facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 7 of 11 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 395796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomeryville Skilled Nursing and Rehabilitati 640 Bethlehem Pike Montgomeryville, PA 18936 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 Based on policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide tracheostomy care consistent with professional standards of practice for one of one sampled resident reviewed for tracheostomy. (Resident 45) Residents Affected - Few Findings include: The facility policy entitled, Tracheostomy Care, last reviewed on February 14, 2023, revealed that tracheostomy care was to be done at least twice a day and as needed per physician's orders. The policy included a statement to cleanse under the trach holder and to replace the trach holder if soiled. Clinical record review revealed that Resident 45 had diagnoses that include acute respiratory failure with hypoxia, tracheostomy (an opening surgically made through the neck into the windpipe, which a tube/cannula allows the passage of air and supplemental oxygen), and laryngeal (voice box) cancer. Observation of Resident 45 on May 30, 2023, at 11:10 a.m. and May 31, 2023, at 10:40 a.m., revealed that Resident 45's tracheostomy collar was visibly soiled and encrusted with a dry green substance. In an interview on May 30, 2023, at 11:15 a.m., Resident 45 stated that the tracheostomy collar hadn't been changed in weeks. There was no documentation to support that Resident 45's tracheostomy collar had been changed during April or May 2023. In an interview on June 01, 2023, at 10:35 a.m., the Director of Nursing confirmed that Resident 45's tracheostomy care was not done according to policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 8 of 11 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 395796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomeryville Skilled Nursing and Rehabilitati 640 Bethlehem Pike Montgomeryville, PA 18936 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for three of 25 sampled residents. (Residents 41, 97, 115) Residents Affected - Some Findings include: Clinical record review revealed that Resident 41 had diagnoses that included osteoarthritis and spinal stenosis. There was a physician's order, dated May 1, 2023, for staff to provide the resident with narcotic pain medication (oxycodone) every six hours as needed for pain. Review of the May 2023, medication administration records (MARs) and nursing notes revealed there was a lack of documentation to support that the resident was offered non-pharmacological interventions prior to or in conjunction with the administration of the as needed pain medication on 20 of 39 occurrences. On May 23, 2023, the physician's order changed for staff to administer the as needed narcotic pain medication (oxycodone) every four hours as needed for pain. Review of the May 2023, MARs and nursing notes revealed there was a lack of documentation to support that the resident was offered non-pharmacological interventions prior to or in conjunction with the administration of the as needed pain medication on 8 of 12 occurrences. Clinical record review revealed that Resident 97 had diagnoses that included chronic pancreatitis and neurogenic bladder (urinary condition caused by lack of bladder control due to either a brain, spinal cord or nerve problem). There was a physician's order, dated May 8, 2023, for staff to provide the resident with narcotic pain medication (tramadol) every twelve hours as needed for pain. Review of the May 2023, MARs and nursing notes revealed there was a lack of documentation to support that the resident was offered non-pharmacological interventions prior to or in conjunction with the administration of the as needed pain medication on 21 of 23 occurrences. Clinical record review revealed that Resident 115 had diagnoses that included spinal stenosis (a condition where the space inside your spine becomes too narrow) and low back pain The resident had a physician's order dated May 5, 2023, for a narcotic pain medication, (tramadol), to be administered every eight hours as needed for pain. Review of the MARs revealed that the resident received the as needed narcotic pain medication 16 times in May 2023, without documented evidence to support that non-pharmacological interventions were offered to address the assessed pain prior to the administration of the as needed narcotic pain medication. During an interview on June 01, 2023, at 10:35 a.m., the Director of Nursing confirmed there was no evidence to support that non-pharmacological interventions were offered to Resident's 41, 97, and 115 to address the pain prior to the administration of the as needed narcotic pain medications. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 9 of 11 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 395796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomeryville Skilled Nursing and Rehabilitati 640 Bethlehem Pike Montgomeryville, PA 18936 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 three of 25 sampled residents. (Residents 47, 50, 90) Residents Affected - Few Findings include: Review of the facility policy entitled, Assessment Grid, dated February 14, 2023, revealed that staff was to assess and monitor a resident for abnormal involuntary movements and adverse side effects upon a new order for antipsychotic medication and every six months when on an antipsychotic medication. Clinical record review revealed that Resident 47 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, major depressive disorder, and anxiety. Since admission, the physician ordered that the resident receive an antipsychotic medication (olanzapine). The 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 to support that nursing staff monitored the resident for abnormal involuntary movements and adverse side effects per facility policy. Clinical record review revealed that Resident 50 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease and bipolar disorder. Since admission, the physician ordered that the resident receive an antipsychotic medication (risperidone). The 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 abnormal involuntary movements and adverse side effects per facility policy. Clinical record review revealed that Resident 90 was admitted to the facility on [DATE], with diagnoses of dementia and major depressive disorder. Since admission, the physician ordered that the resident receive an antipsychotic medication (quetiapine fumarate). The 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 abnormal involuntary movements and adverse side effects per facility policy. In an interview on June 1, 2023, at 9:45 a.m., the Director of Nursing stated that there was no documentation to support that the aforementioned residents were monitored for abnormal involuntary movements and adverse side effects per facility policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 10 of 11 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 395796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomeryville Skilled Nursing and Rehabilitati 640 Bethlehem Pike Montgomeryville, PA 18936 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policy and observation, it was determined that the facility failed to store food under sanitary conditions on the nursing units. (Rehabilitation and Second floor nursing units) Residents Affected - Some Findings include: Review of facility policy entitled, Food Brought in for Patients/Residents, last reviewed February 14, 2023, revealed that all items would be labeled and dated with the resident's name and date that the food was brought in and that after three days would be discarded. Observation of the refrigerator on the rehabilitation nursing unit on May 31, 2023, at 12:59 p.m. revealed a container of takeout food and lunch bags that were brought into the facility and were not labeled or dated. There were numerous dried liquid stains throughout the refrigerator. Observation of the refrigerator on the second floor nursing unit on May 31, 2023, at 11:45 a.m., revealed a container of mixed vegetables, two unidentified food items wrapped in foil, and a container of salad that were brought into the facility and were not labeled or dated. The shelves of the refrigerator had numerous dried brown and red stains and various food crumbs throughout. In the freezer there was three empty disposable drink cups. 28 Pa. Code 201.18(b)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395796 If continuation sheet Page 11 of 11