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Inspection visit

Health inspection

ST MARTHA CENTER FOR REHABILITATION & HEALTHCARECMS #3958151 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395815 01/08/2026 St Martha Center for Rehabilitation & Healthcare 470 Manor Ave Downingtown, PA 19335
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 Page 1 of 2 395815 395815 01/08/2026 St Martha Center for Rehabilitation & Healthcare 470 Manor Ave Downingtown, PA 19335
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 to keep head of bed elevated to prevent shortness of breath while lying flat every shift for shortness of breath were not followed on January 2, 2025, day and evening shift, January 4, 2025, day and evening shift, and January 5, 2025, evening shift. Interview conducted with Director of Nursing (DON) on January 8, 2026, at 10:05a.m. when the above information was presented the DON confirmed the orders were not followed. 28 Pa. Code 211.5(f) Clinical Records28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services 395815 Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

FAQ · About this visit

Common questions about this visit

What happened during the January 8, 2026 survey of ST MARTHA CENTER FOR REHABILITATION & HEALTHCARE?

This was a inspection survey of ST MARTHA CENTER FOR REHABILITATION & HEALTHCARE on January 8, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ST MARTHA CENTER FOR REHABILITATION & HEALTHCARE on January 8, 2026?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.