Inspection·August 29, 2023

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on resident and staff interviews, observations, and facility documentation review it was determined the facility failed to have adequate number of dietary staff to meet the needs of the residents. Residents Affected - Many Findings Include: Interviews conducted with Resident R1, R2, R3, R4, and R5 on August 29, 2023 between 9:15 and 9:50 a.m. revealed the breakfast trays are always late for the residents and arrive between 9:15 a.m. and 10:15 a.m. Observations of the breakfast tray delivery on August 29, 2023 revealed the last tray was delivered to a resident on the 600 hall at 10:10 a.m. Observation of the dining room during the breakfast meal revealed the dining room was not being used and a sign was posted to the door that it opens at 8:15 a.m. Interview with Dietary Director Employee E3 on August 29, 2023 at 10:35 a.m. revealed the kitchen was short staffed the day of the survey. The kitchen should be staffed with three staff on tray line, on staff member to pushed the completed carts to the units and one cook and one dishwasher, today the kitchen was staffed with one staff on tray line, on to push the carts and one dishwasher with another staff who came in to put the order that delivered away and the dietary director helping in the kitchen with production. The dietary director confirmed the kitchen was short of two staff members for the breakfast meal. Review of the facility assessment, last assessed on July 25, 2023 revealed the facility needs on average 5-7 staff members per meal. Further interview with the Dietary Director Employee E3 on August 29, 2023 confirmed the meal trays were late and that the dinning room was not open because there was not enough dietary staff to have breakfast served both in the dinning room and on the units. Interview with the Nursing Home Administrator and the Director of Nursing on August 29, 2023 at 11:00 a.m. confirmed there was not a sufficient number of staff in the kitchen to meet the needs of the residents resulting in breakfast being delivered late and the residents not being able to eat in the dining room if preferred. 28 Pa Code 211.6(c) Dietary services. (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 2 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 08/29/2023 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)