Inspection·January 8, 2026

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 clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding oxygen and catheter care for 1 of 8 resident's reviewed (Resident 10).Findings include: Review of Resident 10's face sheet revealed medical diagnoses that include Obstructive and Reflex Uropathy (blockage in urinary tract), Urine Retention, Atrial Fibrillation (irregular often very rapid heart rhythm). Review of Resident 10's physician orders revealed orders dated September 5, 2025, to provide foley catheter care every shift. Review of Resident 10's December 2025, Medication Administration Report (MAR), revealed orders for foley catheter care every shift were not followed on December 2, 2025, day and evening shift, December 4, 2025, day shift, December 5, 2025, day shift, December 7, 2025, day shift, December 8, 2025, evening shift, December 9. 2025, day shift, December 12, 2025, day and evening shift, December 13, 2025, day shift, December 15, 2025, evening shift, December 20, 2025, evening shift, December 21, 2025,evening shift, December 22, 2025, day shift, December 23, 2025, evening shift, December 24, 2025, evening shift, December 25, 2025, day and evening shift, December 26, 2025, evening shift, December 27, 2025, evening shift, December 28, 2025, day shift, and December 30, 2025 evening shift. Review of Resident 10's January 2026, MAR revealed orders for foley care every shift were not followed on January 2, 2025, day and evening shift, January 4, 2025, day and evening shift, and January 5, 2025, evening shift. Review of Resident 10's physician orders revealed orders dated October 30, 2025, for oxygen at 2 liters via nasal cannula continuously every shift for shortness of breath. Review of Resident 10's December 2025, MAR revealed orders for oxygen at 2 liters via nasal cannula continuously every shift for shortness of breath were not followed on December 2, 2025, day and evening shift, December 4, 2025, day shift, December 5, 2025, day shift, December 7, 2025, day shift, December 8, 2025, evening shift, December 9. 2025, day shift, December 12, 2025, day and evening shift, December 13, 2025, day shift, December 15, 2025, evening shift, December 20, 2025, evening shift, December 21, 2025,evening shift, December 22, 2025, day shift, December 23, 2025, evening shift, December 24, 2025, evening shift, December 25, 2025, day and evening shift, December 26, 2025, evening shift, December 27, 2025, evening shift, December 28, 2025, day shift, and December 30, 2025 evening shift. Review of Resident 10's January 2026, MAR revealed orders for oxygen at 2 liters via nasal cannula continuously every shift were not followed on January 2, 2025, day and evening shift, January 4, 2025, day and evening shift, and January 5, 2025, evening shift. Review of Resident 10's physician orders revealed orders dated September 4, 2025, to keep head of bed elevated to prevent shortness of breath while lying flat every shift for shortness of breath. Review of Resident 10's December 2025, MAR revealed orders to keep head of bed elevated to prevent shortness of breath while lying flat every shift for shortness of breath were not followed on December 2, 2025, day and evening shift, December 4, 2025, day shift, December 5, 2025, day shift, December 7, 2025, day shift, December 8, 2025, evening shift, December 9. 2025, day shift, December 12, 2025, day and evening shift, December 13, 2025, day shift, December 15, 2025, evening Residents Affected - Few (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 01/08/2026 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)