Inspection·January 12, 2024

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. Based on clinical records review, resident and staff interview, it was determined that the facility failed to implement a comprehensive care plan intervention to prevent alteration in nutrition and hydration for one of eight residents reviewed (Resident R14). Findings include: Review of R14's records revealed a care plan dated May 12, 2020, documenting the resident has potential for self-care deficit. Interventions included resident requires eating assist x one person. Further review of R14's records revealed a care plan dated May 12, 2020, with a revision date of November 17, 2023, documenting R14 has the potential for alteration in nutrition and hydration. Intervention dated March 29, 2022, documented the need for staff to assess R14's ability to prepare food/fluids and feed self. Interventions also included the need to offer the resident assistance as needed. An intervention dated September 6, 2023, documented the need for adaptive equipment: lipped plate with meals. Observation of R14 on January 10, 2024, at 09:02 AM, revealed the resident having difficulty eating. The resident had food on her clothes and face. The resident was observed trying to grab a pastry from the table. The pastry was sitting on a tissue, no plate was observed on the table. The resident was able to grab the pastry, but not able to remove the tissue. The resident became frustrated, put the pastry back on the table and didn't attempt to eat it again. Observation of R14 on January 11, 2024, at 09:15 AM, revealed resident in the dining room with a plate on her lap attempting to eat breakfast. The resident was observed with food on her clothing and face. The resident did not have a lipped plate, or a staff person to assist with eating as documented in her care plan. Interview on January 11, 2024, at 09:33 AM with E#3, confirmed that R14 was care planned for a lipped plate and one person assist with eating. Interview on January 12, 2024, at 11:32 AM with DON, confirmed that R14 was care planned for a lipped plate and one person assist with eating. 28 Pa. Code 211.5(f) Clinical records Previously cited 3/18/21 (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 10 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 01/12/2024 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)