Health inspection·May 17, 2024

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 interview, it was determined that the facility failed to monitor a fluid restriction order for one of the 18 residents reviewed (Resident 235). Residents Affected - Few Findings include: Review of Resident 235's diagnosis list includes Congestive Heart Failure (CHF-weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Kidney Failure, and Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life). Review of Resident 235's physician's order dated May 9, 2024, revealed an order for 2000 ml (milliliter) fluid restriction, and heart-healthy modification. The clinical records review failed to reveal evidence that Resident 235's fluid intake was monitored to ensure the 2000 ml fluid restriction ordered by the physician was followed. Interview was conducted with the Director of Nursing on May 17, 2024, at 11:00 a.m. The Director of Nursing confirmed that nursing does not have documented evidence that Resident 235 ' s 2000 ml fluid restriction order was monitored and followed. The facility failed to ensure Resident 235's fluid intake was monitored to ensure the 2000 ml fluid restriction ordered by the physician was followed. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395952 If continuation sheet Page 2 of 5 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 395952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naamans Creek Country Manor 1194 Naamans Creek Road Boothwyn, PA 19061 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review and staff interview, it was determined that the facility failed to ensure skin impairment identified upon admission was comprehensively assessed for two of the six residents reviewed (Resident 57 and 235). Residents Affected - Few Findings include: Review of the facility's policy titled Pressure Injury Management Program Evaluating Risk, Prevention, Support Planning, Treatment, and Monitoring, last reviewed in October 2021, revealed that residents admitted with pressure ulcers receive the care and services necessary to promote healing. A review of the same policy revealed that an evaluation of the pressure ulcer should be documented. At a minimum, documentation must include the date observed and the following: location, size, exudate if present, pain, wound bed, and description of wound edges and surrounding tissue as appropriate. Review of Resident 57's clinical records revealed Resident 57 was admitted to the facility on [DATE], with a diagnosis of Pneumonia. Review of Resident 57's admission skin assessment completed on January 26, 2024, revealed, the resident was admitted with a pressure ulcer (open wound caused by unrelieved pressure that results in damage to the underlying tissue) to the sacrum (tailbone). A review of the same assessment revealed no information regarding the wound's size, and description. Review of Resident 57's clinical records revealed Resident 57 sacral wound was not comprehensively assessed until evaluated by the wound nurse practitioner (NP) on February 5, 2024, 10 days after a wound was identified on admission. Review of Resident 235's clinical records revealed Resident 235 was admitted to the facility on [DATE], with a diagnosis of Dementia and Urinary Tract Infection. Review of Resident 235's admission skin assessment completed in May 2024, revealed the resident was admitted with a pressure ulcer to the right heel. Further review of the same assessment revealed no information regarding the wound's size and description. Review of Resident 235's clinical records revealed Resident 235's right heel wound was not comprehensively assessed until evaluated by the wound Nurse Practitioner on May 13, 2024. Interview was conducted with licensed nurse Employee E5 on May 17, 2024, at 9:30 a.m. Employee E5 reported that the admitting nurse is responsible for assessing the resident's skin for any impairment. Employee E5 added that although nurses don't initially document the stage of the wound, measurements, description of the wound, and the surrounding area should be assessed and documented. An interview with the Director of Nursing conducted on May 17, 2024, confirmed Resident 57 and Resident 235's pressure ulcers should have been comprehensively assessed on admission. The facility failed to ensure Resident 57 and Resident 235's pressure wounds identified upon admission were comprehensively assessed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395952 If continuation sheet Page 3 of 5 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 395952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naamans Creek Country Manor 1194 Naamans Creek Road Boothwyn, PA 19061 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)

F 0686 28 Pa Code 211.5 (f) Clinical records Level of Harm - Minimal harm or potential for actual harm Previously cited 7/20/23. 28 Pa code 211.10 (c) Resident care policies Residents Affected - Few Previously cited 7/20/23. 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 7/20/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395952 If continuation sheet Page 4 of 5 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 395952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naamans Creek Country Manor 1194 Naamans Creek Road Boothwyn, PA 19061 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain dish machine water temperatures by manufacturer recommendations for food service safety in the main kitchen. Findings include: A review of the facility's policy titled Machine Ware Washing undated, revealed that dining services will properly clean and sanitize all service ware to destroy foodborne pathogens. The same policy revealed that the staff will monitor/document water temperatures routinely in the Mechanical ware washer water temperature log. Monitoring schedule: at least one time every meal (mid-morning - breakfast clean-up, mid-afternoon - lunch clean-up, and evening - supper clean-up). Standard temperature = Wash = > 150 F. Final Rinse = > 180 F. A kitchen tour was conducted on May 14, 2024, at 9:34 a.m., with the presence of the Food Director Employee E4. An observation of the dish machine was conducted and revealed drinking cups and plates were being washed. An observation of the Wash temperature gauge revealed a temperature of 140F. The Rinse temperature gauge was observed not moving and was kept to 0 F. A review of the dishwater temperature log revealed that the water temperature was last checked on the evening of May 13, 2024. The temperature log for the morning of May 14, 2024, was blank. An interview was conducted with Employee E4 on May 14, 2024, at 9:45 a.m., who reported that the dish machine was recently serviced/checked by Ecolab and was functioning well until today. The above was conveyed to the Nursing Home Administrator on May 14, 2024, at 9:50 a.m. The facility failed to ensure dish machine water temperature in the main kitchen was maintained according to the manufacturer's recommendations for food service safety. 42 CFR 483.60(i)(2) Food Procurement, Store/Prepare/Serve-Sanitary 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395952 If continuation sheet Page 5 of 5