Health inspection·January 22, 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 review of clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medication administration times were following according to physician order for three of three residents reviewed. (Resident R1, Resident R2, Resident R3)Findings include: Review of an undated facility policy, Administration of Medication, under section 6.1 Medication Administration Times, revealed Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed no later than sixty (60) minutes after designated times of administration. Further review revealed Facility should administer medications ordered before meals approximately thirty (30) minutes before mealtimes and should administer medications ordered to be given after meals no later than thirty (30) minutes after a meal has ended. Review of facility meal delivery schedule revealed the following times for all nursing units, Breakfast delivery between 07:35a.m. - 8:25a.m.; Lunch delivery between 11:45a.m. - 12:35p.m.; Dinner Delivery between 4:30p.m. - 6:35p.m. Note: All times are approximate within 10 minutes. Interview with Employee E3, Food Director, on January 22, 2026 at 12:45p.m. revealed no concerns regarding late delivery of food trucks to units, Usually we deliver on time. Interview with Employee E1, Nursing Home Administrator on January 22, 2026 at 1:25p.m. revealed no concerns regarding late delivery of food trucks to units. Confirmed that food trucks are normally delivered on time. No documented evidence of delivery times. Review of Resident R1's clinical record revealed admission date to the facility of November 14, 2025, with diagnosis of Type 2 diabetes. Review of Resident R1's clinical record revealed BIMS (Brief Interview for Mental Statue) score of 15, indicating cognitively intact. Interview with Resident R1 on January 22, 2025 at 10:29 a.m. revealed that medications are late often. Review of Resident R1 MAR (Medication Administration record) dated December 22, 2025 through December 31, 2025 revealed the following: December 22, 2025- Ordered schedule time 5:00p.m.- 7:00p.m; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 8:40 p.m. Documentation notes late Administration: Charted late. No documented evidence of reason or physician notification. December 26, 2025- Ordered schedule time 5:00p.m.- 7:00p.m; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 9:21 p.m. Documentation notes late Administration: Charted late. No documented evidence of reason or physician notification. December 27, 2025- Ordered schedule time 08:00a.m.- 10:00a.m.; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 10:39a.m. Documentation notes late Administration: Charted late. Comment: admin. No documented evidence of reason or physician notification. December 27, 2025- Ordered schedule time 5:00p.m.- 7:00p.m; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 8:18 p.m. Documentation notes late Administration: Charted late. No documented evidence of reason or physician notification. December 28, 2025- Ordered schedule time 5:00p.m.- 7:00p.m; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 9:02 p.m. Documentation notes late Residents Affected - Few Page 1 of 5 395912 395912 01/22/2026 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administration: Charted late. No documented evidence of reason or physician notification. December 22, 2025- Ordered schedule time 9:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 10:21p.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 23, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 09:12 a.m. Documentation notes late administration: charted late. Comment: admin. No documented evidence of reason or physician notification. December 24, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 09:14 a.m. Documentation notes late administration: charted late. Comment: admin. No documented evidence of reason or physician notification. December 24, 2025- Ordered schedule time 11:30 a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 1:32p.m. Documentation notes late administration: charted late. Comment: admin. No documented evidence of reason or physician notification. December 25, 2025- Ordered schedule time 8:00 a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:42 a.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 25, 2025- Ordered schedule time 11:30 a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 2:05 p.m. Documentation notes late administration: charted late. Comment: admin. No documented evidence of reason or physician notification. December 26, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:30a.m. Documentation notes late administration: charted late Comment: admin. No documented evidence of reason or physician notification. December 26, 2025- Ordered schedule time 4:30p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:20p.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 27, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 10:39a.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 28, 2025- Ordered schedule time 11:30a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 2:19p.m. Documentation notes late administration: charted late. Comment: Admin. No documented evidence of reason or physician notification. December 28, 2025- Ordered schedule time 4:30p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:02p.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 29, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 10:12a.m. Documentation notes late administration: charted late. Comment: g. No documented evidence of reason or physician notification. December 30, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:55 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. December 31, 2025- Ordered schedule time 11:30a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 1:26p.m. Documentation notes late administration: charted late. Comment: n/a. No documented 395912 Page 2 of 5 395912 01/22/2026 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evidence of reason or physician notification. December 31, 2025- Ordered schedule time 4:30p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 5:38p.m. Documentation notes late administration: charted late. Comment: 0. No documented evidence of reason or physician notification. Review of Resident R2 clinical record revealed admission date to the facility of September 30, 2025 with diagnosis of Hip replacement, Type 2 diabetes. Review of Resident R2 clinical record revealed BIMS (Brief interview for Mental Status) score of 14, indicating cognitively intact. Interview with Resident R 2 on January 22, 2025 at 10:40 a.m. revealed concerns related to insulin. Insulin is often given long after my meals, sometimes a few hours and I am supposed to receive it prior to meals. Review of Resident R2 MAR (Medication Administration record) dated January 1, 2026 through January 22, 2026 revealed the following: January 2, 2026- Ordered schedule time 11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:37 p.m. Documentation notes late administration: charted late. Comment: cl. No documented evidence of reason or physician notification. January 3, 2026- Ordered schedule time 8:00a.m.-9:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 9:59 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 3, 2026- Ordered schedule time 11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 12:54 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 4, 2026- Ordered schedule time 8:00a.m.-9:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 10:42 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 4, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 3:30 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 6, 2026- Ordered schedule time 8:00a.m.-9:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 11:21 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 7, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:15 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 8, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 3:37 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 9, 2026- Ordered schedule time 4:30p.m.-5:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 6:36 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 10, 2026- Ordered schedule time 4:30p.m.-5:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 6:38 p.m. Documentation 395912 Page 3 of 5 395912 01/22/2026 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notes late administration: charted late. Comment: given. No documented evidence of reason or physician notification. January 11, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:39 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 12, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 2:25 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 13, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:39 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 14, 2026- Ordered schedule time 8:00a.m.-9:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 10:17 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 14, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:42 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification.January 16, 2026- Ordered schedule time 8:00 a.m.-9:00 a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 10:34 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 16, 2026- Ordered schedule time 4:30p.m.-5:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 7:21 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 18, 2026- Ordered schedule time 11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:26 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 20, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:54 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 21, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:43 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. Review of Resident R3 clinical record revealed admission date to the facility of June 17, 2021, with diagnosis of Scapula fracture, Type 2 diabetes. Review of Resident R3 clinical record revealed BIMS (Brief interview for Mental Status) score of 15, indicating cognitively intact. Interview with Resident R3 on January 22, 2025 at 10:08 a.m. revealed received morning medications late, this happens all the time, medications are always late, especially at night. Review of Resident R3 MAR (Medication Administration record) dated December 25, 2025 through January 22, 2026 revealed the following: December 30, 2025- Ordered schedule time 8:00 a.m. - 11:00a.m; Amlodipine 10mg Tablet, give 1 tablet by mouth in the morning related to essential 395912 Page 4 of 5 395912 01/22/2026 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (primary) hypertension. Administered at 12:31 p.m. Documentation notes late Administration: Charted late Comment N/A. No documented evidence of reason or physician notification. December 30, 2025- Ordered schedule time 8:00a.m- 10:00a.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 12:31 p.m. Documentation notes late Administration: Charted late Comment N/A. No documented evidence of reason or physician notification. January 5, 2026 - Ordered schedule time 8:00 a.m. - 11:00a.m; Amlodipine 10mg Tablet, give 1 tablet by mouth in the morning related to essential (primary) hypertension. Administered at 11:35 a.m. Documentation notes late Administration: Other. Comment N/A. No documented evidence of reason or physician notification. January 6, 2026- Ordered schedule time 8:00 a.m. - 11:00a.m; Amlodipine 10mg Tablet, give 1 tablet by mouth in the morning related to essential (primary) hypertension. Administered at 11:12 a.m. Documentation notes late Administration: Charted late Comment N/A. No documented evidence of reason or physician notification. January 2, 2026 Ordered schedule time 4:00p.m- 7:00p.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 8:40 p.m. Documentation notes late Administration: Charted late Comment g. No documented evidence of reason or physician notification. January 5, 2026- Ordered schedule time 8:00a.m- 11:00a.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 11:35 a.m. Documentation notes late Administration: Other. Comment N/A. No documented evidence of reason or physician notification. January 6, 2026- Ordered schedule time 8:00a.m- 11:00a.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 11:12 a.m. Documentation notes late Administration: Charted late Comment No documented evidence of reason or physician notification. January 8, 2026- Ordered schedule time 4:00 p.m- 7:00 p.m: OxycodoneSchedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 7:14 p.m. Documentation notes late Administration: Charted late Comment ok. No documented evidence of reason or physician notification. January 9, 2026- Ordered schedule time 4:00p.m.- 7:00p.m.: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 7:07 p.m. Documentation notes late Administration: Charted late Comment ok. No documented evidence of reason or physician notification. January 16, 2026- Ordered schedule time 4:00 p.m.- 7:00p.m.: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 7:58 p.m. Documentation notes late Administration: Charted late. No documented evidence of reason or physician notification. January 21, 2026- Ordered schedule time 4:00p.m- 7:00p.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 7:07 p.m. Documentation notes late Administration: Charted late Comment ok. No documented evidence of reason or physician notification. Interview with Employee E2, Director of Nursing on January 22, 2026 at 1:30p.m. confirmed above referenced findings and revealed when medications are late they have to be manually entered into the chart and documented as late. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395912 Page 5 of 5