Inspection·February 21, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policy, observations, clinical records and staff interviews, it was determined that the facility failed to follow physician orders for two of 22 residents reviewed (Resident 86 and 164). Residents Affected - Few Finding include: A review of the facility's policy regarding Enteral Nutrition, dated March 2020, revealed adequate nutritional support through enteral feeding will be provided to residents as ordered. A review of Resident 86's clinical records revealed medical diagnoses that include Dysphagia following other Cerebrovascular Disease (swallowing disorder that occurs after a stroke or other neurological disease), Muscle Wasting and Atrophy (loss of muscle mass), and Severe Protein-Calorie Malnutrition (inadequate protein or calories in diet). Review of Resident 86's clinical records revealed a physician order dated January 9,2025, for Jevity 1.5 at 40ml/ per hour x20 hours via Kangaroo pump (pump that delivers nutrition through a tube inserted in the stomach or intestine that's programmed with desired feed rate and volume), total volume 800ml per day or until infused. Down at 11am, up at 3pm. This provides 1200 kcal, 51g protein and 608ml free water every shift for Peg-Tube. Observations of Resident 86's Kangaroo pump on February 18, 2025, at 9:30 a.m., revealed the pump was already disconnected from the resident and turned off. Observations of Resident 86's Kangaroo pump on February 19, 2025, at 9:40 a.m., revealed the pump was already disconnected from the resident and turned off. A review of Resident 86's February Medication Administration Record (MAR) revealed the resident received the following amounts of Jevity daily: February 1-2, 300ml evening, 0ml night, 160ml day for a total of 460ml February 2-3 320ml evening, 230ml night, 160ml morning for a total of 480 ml February 3-4 320ml evening, 230ml night, 160ml morning for a total of 780ml February 4-5 250ml evening, 0ml night, 160ml morning for a total of 420 ml February 5-6 320ml evening, 40ml night, 160ml morning for a total of 520ml (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 4 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 02/21/2025 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)