Health inspection·February 11, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, record review, and interviews with residents and staff it was determined that the facility did not ensure a safe, clean, comfortable, homelike environment for three of three nursing units reviewed related to the air temperatures. (100 Wing, 200 Wing, 300 Wing)Findings Include: Review of the facility policy titled, Homelike Environment with a revision dated of February 11, 2026 states, Policy Statement- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy states, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:.h. comfortable and safe temperatures (71 degrees Fahrenheit to 81 degrees Fahrenheit). A tour was taken of each of the nursing units with Employee E1, Administrator, Employee E2, Director of Nursing, and Employee E4 promptly upon entrance to obtain air temperature of resident commons areas and resident rooms. At 9:39 a.m. the air temperature was taken of Resident R1's room, room [ROOM NUMBER]. The temperature of the room at the time was 69.6 degrees Fahrenheit. The room was observed with large windows next to the bed. The thermostat for the room was set at 73 degrees Farenheit.Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set) completed on January 23, 2026 revealed a BIMS (Brief Interview for Mental Status) of 15 indicating high cognitive function.An interview was held with Resident R1 at 11:58 a.m. and when asked if the room gets cold Resident R1 stated, yes, especially at nighttime. At 9:44 a.m. the air temperature was taken of Resident R2's room, room [ROOM NUMBER].The temperature of the room at the time was 66 degrees Fahrenheit. The thermostat for the room was set at 73 degrees Fahrenheit. Resident R2 was asleep at the time of taking the air temperature. The room was observed to have baseboard heating, and one window was cracked approximately one centimeter. The air temperature was retaken of resident R2's room at 11:38 a.m. the temperature at the time was 72.3 degrees. At this time Resident R2 was interviewed. Resident R2 stated that at the time of the interview the temperature of her room is comfortable. When asked if the resident likes her room to be cold, warm, or in the middle she stated, in the middle. When asked if she likes to have the window always cracked she stated, yes, I do because the temperature goes up and down and sometimes it is too hot. When asked if the room ever gets too cold the resident stated, yes, especially on the weekends. At 9:52 a.m. the air temperature was taken for Resident R3 in room [ROOM NUMBER]. The temperature of the room at the time 66.7 degrees Fahrenehit. The thermostat was observed at 74 degrees Fahrenheit. Resident R3 could not be interviewed based on cognitive status. The resident has the following diagnosis: Chronic Respiratory Failure with Hypoxia (a long-term condition where the lungs cannot adequately transfer oxygen into the blood, resulting in low blood oxygen levels), Acute Respiratory Failure (life-threatening, sudden Page 1 of 3 395847 395847 02/11/2026 Montgomery Subacute and Respiratory Center 251 Stenton Avenue Plymouth Meeting, PA 19462

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (acute) inability of the respiratory system to maintain proper gas exchange), Tachycardia (an increased heart rate for any reason), Dysphagia (difficulty swallowing), and Convulsions (sudden, involuntary, and violent muscle contractions and relaxations, causing rapid, rhythmic shaking, often with loss of consciousness). At 9:57 a.m. the air temperature was taken for Resident R4 in room [ROOM NUMBER].The temperature of the room was 62.9 degrees Fahrenheit. The room was observed to have baseboard heating, and one window still has an air conditioning unit in it. The thermostat for the room was observed at 74 degrees Fahrenheit.Resident R4 admitted to the facility on [DATE]. Review of Resident R4's clinical record revealed an MDS (Minimum Data Set) completed on January 29, 2026 revealed a BIMS (Brief Interview for Mental Status) score of 12 for the resident.Resident R4 was interviewed at the time of taking the air temperature and stated that she was cold. Resident R4 asked for another blanket and to turn the heat up. An interview was held with Resident R4's daughter at 12:13 p.m. and she stated there were a few days when Resident R4's arm felt cold to the touch. The air temperature was taken of room [ROOM NUMBER] for Resident R5 and Resident R6. The temperature of the room at 10:14 a.m. was 69.2 degrees Fahrenheit. Both residents R5 and R6 could not be interviewed based on cognitive status.An air temperature was taken of room [ROOM NUMBER] for Resident R7.The temperature of the room at the time was 67.4. The room was observed to have a PTAC (Packed Terminal Air Conditioner) unit that was currently functioning and on. The resident was asleep at the time of observation. Interview held with the Nursing Home Administrator and Director of Nursing at 10:15 a.m They were both asked if they had seen any air temperature logs for the past few months. The Nursing Home Administrator stated at 10:19 a.m I don't know where the logs are or how often the maintenance director is currently taking temperatures. An interview was held with the Director of Nursing Employee E2 at 10:28 a.m. and she confirmed that the facility does have rooms that vary with temperatures throughout the day. When asked if temperatures are being taken on the evening or overnight shift, Employee E2 stated, no, but they were at one point having the weekend staff check the water temperatures but not the air temperatures. The maintenance director was asked to provide air temperature monitoring logs for the months of November 2025, December 2025, January 2026, and February 2026. The surveyor was given documentation for November and December 2025 but after further examination the date of 2024 was crossed out and all the dates indicated on the left-hand side were all from 2024. Logs from 2024 and 2025 were requested. The Director of Maintenance Employee E3 and the Regional Director of Maintenance Employee E5 produced documentation at 12:35 p.m. An interview was held with the Director of Maintenance Employee E3 at 12:37 p.m. The Director of Maintenance Employee E3 was asked how the dates for 2024 were crossed out and logs from 2024 and 2025 were the same as the previous year including dates and air temperatures. At 12:42 p.m. Employee E3 confirmed that he had copied the logs from 2024. When asked if he was monitoring air temperatures for the months of November and December he stated, no, we just started checking them in January when the temperatures started to drop and there was a complaint. Further interview with Regional Director of Maintenance revealed currently in the maintenance electronic tracking system it is only set up for the Director Maintenance to check air temperatures in the facility once a week. Employee E5 explained that for the 300 wing some of the rooms have thermostats that are controlled at a central area where there may be visitors that were adjusting them. Recently they purchased clear locked coverings for the thermostat in the attempt to prevent this. When asked who has access to the key Employee E5 stated that Employee E3 does.At interview was held with the Nursing Home Administrator Employee E1 and Director of Nursing E2 who both confirmed at 2:04 p.m. that there was no oversight of air temperature logs from maintenance by them during the months of November, December, January, or February. Employee E1 and Employee E2 were asked about who would 395847 Page 2 of 3 395847 02/11/2026 Montgomery Subacute and Respiratory Center 251 Stenton Avenue Plymouth Meeting, PA 19462

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be responsible for adjusting the heat for evening or overnight if the residents were cold due to the Director of Maintenance Employee E3 being the only one who has a key. Employee E1 and Employee E2 stated that at this time Employee E3 is the only one with a key and he is on call and can come in if necessary. During the month of January in Plymouth Meeting, where the facility is located were several recorded low cold days including January 24, January 26, and January 28, and January 31. The date of January 31 was a Saturday. During the month of February in Plymouth Meeting, where the facility is located, there were several recorded low cold days including February 7 and February 8. The date of February 7 was a Saturday, and the date of February 8 was a Sunday. 395847 Page 3 of 3