Inspection·April 27, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on a review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to report an allegation of misappropriation of resident property to the appropriate State agencies for three of nine residents reviewed (Residents R1, R2, and Resident R3). Findings include: Review of facility policy Abuse Prevention/ Reporting revised April 2022, revealed that the facility will report all alleged violations involving mistreatment, neglect or abuse to the Department of Health, Division of Nursing Facilities, and to other agencies required by law and Act 13. Review of Resident R1's progress note of March 9, 2023, revealed that Resident R1 was admitted to the hospital. Review of Resident R1's Individual Patient Controlled Substance Administration Record revealed that one tablet of Oxycodone IR (opioid used to help relieve moderate to severe pain) 5 milligrams (mg) was signed out on March 10, 2023, by licensed staff Employee E3. Review of Resident R2's physician's orders included an order for Tramadol (opioid used to help relieve moderate to severe pain) 50 mg one tablet twice a day. Review of the March 2023 Medication Administration Record (MAR) revealed that it was to be administered at 9:00 a.m. and 6 p.m. Review of Resident R2's Individual Patient Controlled Substance Administration Record revealed that one tablet was signed out on March 12, 2023 at 3:00 a.m. by licensed staff Employee E3. Further review of the clinical record revealed no evidence that the resident received Tramadol at 3:00 a.m. on March 12, 2023. Review of Resident R3's physician's orders included an order for Oxycodone/APAP 5/325 mg (Percocet used to help relieve moderate to severe pain) two tablets once daily. Review of the March 2023 Medication Administration Record (MAR) revealed that it was to be administered at 9:00 a.m. Review of Resident R3's Individual Patient Controlled Substance Administration Record revealed that one tablet was signed out on March 10, 2023 at 1:15 a.m. and two tablets on March 11, 2023, at 11:30 p.m. by licensed staff Employee E3. Further review of the clinical record revealed no evidence that the resident received Oxycodone/APAP at those times. Interview with the Director of Nursing (DON) on April 27, 2023, at 10:45 a.m. revealed that the DON was notified that Employee E3 had signed out medication for Resident R1 while Resident R1 was hospitalized and that Employee E3 was not always documenting on the resident MARs. Employee E3's agency was made aware of the issues and was asked to not return to the facility. The DON confirmed that the allegation of misappropriation was not reported to the Department of Health. (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 3 Event ID: 395815 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 395815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Martha Center for Rehabilitation & Healthcare 470 Manor Ave Downingtown, PA 19335 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)