Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Martha Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
A resident with urinary and cardiac conditions had physician orders for Foley catheter care every shift, continuous O2 at 2L via nasal cannula, and head-of-bed elevation for SOB that were not carried out on multiple day and evening shifts over an extended period, as evidenced by gaps in the MAR and confirmed by the DON.
The facility failed to follow physician orders for two residents. One resident with dysphagia and malnutrition did not receive the prescribed amount of enteral nutrition via a Kangaroo pump, as the pump was often disconnected early. Another resident with Type II Diabetes Mellitus missed several doses of Insulin Aspart, with no parameters for holding the insulin or physician notification documented. These deficiencies were confirmed by the DON.
The facility failed to ensure appropriate indications and non-pharmacological interventions before administering as-needed anti-anxiety medications for two residents. One resident received Ativan gel without proper indication or non-pharmacological attempts, while another received Clonazepam without appropriate indication or non-pharmacological interventions. These deficiencies were confirmed with the DON.
The facility failed to ensure corridor doors positively latch and resist smoke passage, affecting two smoke compartments. Observations revealed that the Main Street Cafe doors did not latch, and the Sunflower Cafe door had a gap over 1/2 inch, compromising smoke resistance. These issues were confirmed by the Director of Plant Operations.
The facility failed to maintain a fire-rated door separating Nursing Care from Assisted Living, compromising fire safety. The door had been modified, resulting in gaps and unauthorized repairs, affecting one of ten smoke compartments. The Director of Plant Operations confirmed these deficiencies.
The facility was found to be non-compliant with NFPA 101 standards as soiled linen was improperly stored on the floor under the sink in the 300 Wing Tub Room, outside a rated room or container. This was confirmed by the Director of Plant Operations.
Failure to Follow Physician Orders for Catheter Care and Oxygen Therapy
Penalty
Summary
The facility failed to follow multiple physician orders for one resident with diagnoses including obstructive and reflex uropathy, urine retention, and atrial fibrillation. Physician orders dated September 5, 2025, directed that Foley catheter care be provided every shift. Review of the resident’s December 2025 and January 2026 MARs showed numerous shifts on which Foley catheter care was not documented as provided, including multiple day and evening shifts across both months. The resident also had physician orders dated October 30, 2025, for continuous oxygen at 2 liters via nasal cannula every shift for shortness of breath, and orders dated September 4, 2025, to keep the head of the bed elevated every shift to prevent shortness of breath while lying flat. Review of the December 2025 and January 2026 MARs revealed that these oxygen and head-of-bed elevation orders were not followed on the same multiple day and evening shifts where Foley care was missed. During an interview on January 8, 2026, at 10:05 a.m., the DON was presented with this information and confirmed that the physician orders had not been followed.
Failure to Follow Physician Orders for Enteral Nutrition and Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. Resident 86, who has medical diagnoses including dysphagia, muscle wasting, and severe protein-calorie malnutrition, was prescribed Jevity 1.5 at 40ml per hour for 20 hours via a Kangaroo pump, totaling 800ml per day. Observations on two separate days revealed that the pump was disconnected and turned off before the prescribed amount was administered. A review of the resident's Medication Administration Record (MAR) for February showed that the resident never received the full prescribed amount of tube feed on any day. The Director of Nursing confirmed that the amounts documented on the MAR did not match the physician's orders. Resident 164, diagnosed with Type II Diabetes Mellitus, had a physician's order for Insulin Aspart to be administered every six hours. However, the insulin was not administered seven times between February 1 and February 18. The MAR indicated that the insulin was held due to blood sugar levels being within limits or other unspecified reasons, but there were no parameters provided for holding the insulin. Additionally, there was no documentation that the physician was notified about the missed doses. The deficiencies were confirmed with the Director of Nursing, who acknowledged the discrepancies between the physician's orders and the care provided. The facility's failure to administer the prescribed treatments as ordered for both residents highlights a significant lapse in following medical directives, which is crucial for maintaining the health and well-being of residents with complex medical needs.
Failure to Ensure Appropriate Use of As-Needed Anti-Anxiety Medications
Penalty
Summary
The facility failed to ensure that appropriate indications and non-pharmacological interventions were provided before administering as-needed anti-anxiety medications for two residents. Resident 3 had a physician's order for Ativan gel to be applied topically for anxiety, both routinely and as needed. However, from November 1 to November 30, 2024, the as-needed Ativan gel was administered seven times without appropriate indication and five times without attempting non-pharmacological interventions. Similarly, Resident 22 had a physician's order for Clonazepam to be administered as needed for anxiety. From January 17 to January 31, 2025, the as-needed Clonazepam was administered nine times without appropriate indication, and non-pharmacological interventions were not attempted before its administration. These deficiencies were confirmed with the Director of Nursing, indicating a failure in the facility's protocol for administering psychotropic medications.
Deficiency in Corridor Door Maintenance
Penalty
Summary
The facility failed to maintain the corridor doors to positively latch and resist the passage of smoke, affecting two of ten smoke compartments. During an observation on February 5, 2025, at 2:10 PM, it was noted that the double doors to the Main Street Cafe, located by the Activity Room door, did not positively latch. This observation was confirmed through an interview with the Director of Plant Operations at the same time. Additionally, another observation on February 5, 2025, at 2:15 PM, revealed that the door to the Sunflower Cafe had a gap on the strike side greater than 1/2 inch, which compromised its ability to resist the passage of smoke. This deficiency was also confirmed in an interview with the Director of Plant Operations at the time of the observation.
Plan Of Correction
K-0363 (E) Corridor- Doors This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure smoke, fire, and corridor doors will operate as per design. 1. The doors by room, the sunflower café, and double doors by main street café have had the doors repaired and now they close, latch, and are gap free as design. 2. Doors throughout the facility were checked to allow for closure; all residents are free from hazards and all systems are operating as designed as of 2/7/2025. 3. Education completed with maintenance staff regarding monitoring doors and rating labels to ensure they close properly on 2/7/2025. 4. Every quarter for a year, the Maintenance Director or designee will check random doors throughout the facility to ensure the doors are fully closed. This information will then be entered on a log and will be presented to the monthly QAPI meeting.
Fire-Rated Door Deficiency in Smoke Compartment
Penalty
Summary
The facility failed to maintain the integrity of a fire-rated door, which is crucial for ensuring safety in the event of a fire. During an observation, it was noted that the corridor fire-rated door, which separates the Nursing Care area from the Assisted Living area at the breezeway end of the 600 Wing, had been improperly modified. The door had been planed on the strike edge, resulting in gaps greater than 1/8 inch, and a hole in the door had been filled with an unauthorized product. These modifications compromised the door's fire-rating capabilities. The Director of Plant Operations confirmed these deficiencies during an interview conducted at the time of the observation. This issue affected one of the ten smoke compartments within the component, indicating a lapse in maintaining the required fire safety standards as per NFPA 101 guidelines.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to have proper fire rated doors separating Nursing and Assisted Buildings. 1. Replacement of the fire-rated door separating six hundred wings from the assisted living building has been ordered. New fire rated latching hardware will be installed as well. Residents are free from hazards. 2. All rated doors have been inspected, and confirmation of latching and free from gaps completed on 2/7/2025. 3. Education is completed with Maintenance staff to confirm proper door operation of doors on 2/7/2025. 4. Every quarter for a year the Maintenance Director or designee review random doors throughout the building for proper operations. This information will then be entered on a log and will be presented to the QAPI meeting.
Improper Storage of Soiled Linen in Facility
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the storage of soiled linen and trash containers. Specifically, the deficiency was observed in two of ten smoke compartments within the facility. On February 5, 2025, at 2:25 PM, soiled linen was found on the floor under the sink in the 300 Wing Tub Room. This observation was confirmed through an interview with the Director of Plant Operations, who acknowledged that the soiled linen was stored outside a rated room or container, which is a violation of the requirement that soiled linen or trash collection receptacles exceeding 32 gallons must be located in a protected space when not attended.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure no excess of receptacles are utilized. 1. The trash containers exceeding thirty-two gallons that were being utilized to store items have been removed and are no longer utilized in the facility and have been replaced with proper storage containers. The linen under the sink in three hundred wing tubs has been removed as well. 2. Facility wide inspection of any trash containers and under sink storage was completed on 2/7/2025. 3. Education with facility wide staff regarding improper disposal of soiled linen and containers needing to be under 32 gallons in shower and tub rooms, to be completed by 3/21/2025. 4. Weekly random audits to be completed for 12 months by Maintenance Director or designee for compliance. This information will then be entered on a log and will be presented to the QAPI meeting.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Downingtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Exton Post Acute | 3.5 mi | ★★★★★ | 14 | 1 |
| Inn At Freedom Village,the | 3.9 mi | ★★★★★ | 0 | 0 |
| Park Lane Post Acute Llc | 6.4 mi | ★★★★★ | 5 | 0 |
| Barclay Friends | 6.6 mi | ★★★★★ | 0 | 0 |
| West Chester Rehabilitation And Healthcare Center | 6.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.