Health inspection·February 1, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on clinical record review and staff interview, it was determined the facility failed to ensure residents had physician orders corresponding with their end of life care wishes for two of 24 residents reviewed. (Residents 15 and 21) Findings include: Review of Resident 15's clinical record revealed an admission date of November 21, 2023. A POLST (Pennsylvania Orders for Life Sustaining Treatment) located on paper chart indicated the resident wishes but was unsigned. Further review of the clinical record failed to reveal further documentation of who completed the POLST or why it continued to be unsigned. Review of the physician orders from admission indicated the resident was a DNR (Do Not Rescusitate). Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 1, 2024, revealed neither individual knew who completed the POLST documentat and why document was not signed. Administration confirmed the physician's order should not be completed until a family signature or verbal agreement was obtained. Review of Resident 21's clinical record revealed an admission date of June 8, 2023. A POLST dated September 11, 2023, located on the paper chart. Review of the POLST document revealed the resident completed the form and chose to be a Do Not Resuscitate (DNR) in regards to life sustaining treatment. Further review of the physician orders indicated the resident was a Full Code. Interview conducted with the NHA and DON on January 31, 2024 at 10:51 a.m. confirmed the resident's wishes were not reflected in the physician orders. The facility failed to ensure resident rights and to formulate an advance directive reflecting their code status and orders to correspond with that code status. 28 Pa. Code: 201.29 (i) Resident rights 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: 395575 If continuation sheet Page 2 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on clinical record review and staff interviews it was determined that a change in condition for one out of 24 residents (Resident 46) was not reported to the physician and a delay in diagnostic testing for one out of 24 residents (Resident 62) was not reported to the physician. Findings include: Review of Resident 46's clinical record revealed a COVID positive test on December 8, 2023 and the family was notified. There was no further documentation stating that the physician was told of this change in condition. Review of Resident 62's clinical record revealed a nursing note dated December 15, 2023, indicating the resident presented with a productive cough and wheezing presented in b/l lobes (both lungs) on expiration. Resident 02 (oxygen) is 95 on RA (room air). This nurse notified PCP (primary care physician). New orders include Ipratropium-Albuterol Solution QID X3 days (type of inhaler) and Chest X-ray 2 view. This nurse called {xray company] and ordered the xray. Noting the confirmation number. Further investigation revealed that the X-Ray company called the facility and stated that they would be in on the following day. On December 16, 2023, the facility phoned the X-Ray company to confirm that they would be out to complete the order. The company stated that they could not confirm a time, due to the volume of requests. On December 17, 2023, the X-Ray was completed. There is no further information that the physician was notfied of this delay. An interview was conducted on February 1, 2024, at 9:30 a.m. with the Nursing Home Administrator and Director of Nursing, revealed that the physician was not notified of the Resident 46's positive COVID test, nor Residents 62's delay in a diagnostic test. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 3 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation and staff interview it was determined that the facility failed to maintain clean resident care equipment for one of 24 residents (Resident 2). Residents Affected - Few Findings include: Observations conducted during an environmental tour of the facility on January 29, 2024, at approximately 9:05 a.m. on the second floor revealed Resident 2 sitting in a wheelchair with dried brown substance on his/her right armrest and a dried white substance on his/her right armrest. Follow up observations conducted January 30, 2024, at 9:06 a.m. and January 31, 2024, at 8:52 a.m. revealed Resident 2's wheelchair was observed with the same dried brown and white substances on his/her armrests. Interview conducted with the Nursing Home Administrator (NHA) on January 31, 2024, at 1:15 p.m. produced copies of daily wheelchair cleaning logs for the months of December 2023, and January 2024. Review of daily wheelchair logs, revealed Resident 2's wheelchair was last cleaned on December 19, 2023. The Nursing Home Administrator confirmed Resident 2's wheelchair was last cleaned on December 19, 2023. Pa. Code 201.18. (b)(1) Management Pa. Code 201.18. (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 4 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on facility policy, clinical record review, and interviews with staff it was determined that the facility failed to investigate an injury of unknown origin for one of 24 residents reviewed (Resident 66). Residents Affected - Few Findings include: Review of the facility Abuse Policy, dated January 2020, section labeled investigation and Reporting allegation of Abuse guidelines. States All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local state and federal agencies and thoroughly investigated by the administrator and or designee. Investigation -Timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. Review of Resident 66's clinical record revealed a nursing note dated January 6, 2024, stated during the shift, this nurse was notified that the resident is experiencing pain, swelling and hematomas (bruise) on the left foot. Site is warm to the touch, no erythema (unusual redness) present . Resident stated she is having difficulty walking and the symptoms started yesterday (1/5/24). Resident is unsure what happened. Physician was notified and xrays were ordered. Further review of the clinical record failed to revealed any further documentation. Surveyor requested information if the injury was investigated and no further documentation was provided. An interview with the Nursing Home Administrator and Director of Nursing on February 1, 2024 at 9:35 a.m. confirmed the injury of unknown origin was not investigated. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 5 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based upon clinical record review and interview, it was determined the facility failed to complete an accurate Minimum Data Set assessment for one of 18 residents reviewed (Resident 26). Residents Affected - Few Findings include: Review of Resident 26's clinical record revealed an Annual Minimum Data Set (MDS -periodic assessment of resident needs) completed on November 2, 2023. Further review of Resident 26's Annual MDS revealed Resident 26 had a urinary catheter. Review of Resident 26's clinical record failed to reveal evidence of a urinary catheter. Interview on January 31, 2024, at 10:15 a.m. with Employee E3 revealed that the Annual MDS submitted and completed on November 2, 2023, did indicate Resident 26 had a urinary catheter. Additional interview with Employee E3 revealed, Resident 26 did not have a urinary catheter. The above information was conveyed to the Nursing Home Administrator at 10:00 a.m. on February 1, 2024. 28 Pa. Code 211.5(f) Clinical Records Previously cited 3/15/2023 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 6 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 0655 Level of Harm - Minimal harm or potential for actual harm Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on clinical record review and interviews with the staff it was revealed that the facility failed to create a suicidal ideation baseline care plan for one of 24 residents reviewed (Resident 66). Residents Affected - Few Findings include: Review of Resident 66's clinical record revealed an admission date of November 20, 2023. Review of the hospital discharge records revealed that the resident was admitted to the emergency room because her son was concerned about a suicidal statement (with a plan) when they were at home. The resident was admitted to the hospital for suicidal ideation. Review of Resident 66's care plan revealed that suicidal ideation was not on the baseline care plan. An interview with the Nursing Home Administrator and Director of Nursing on February 1, 2024, revealed that the facility did not have a baseline careplan for suicidal ideation. 28 Pa Code 201.18(b)(3) Management 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 7 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based upon review of clinical records, it was determined the facility failed to establish a care plan for the development of a wound for one of 18 residents reviewed (Resident 14). Residents Affected - Few Findings include: Review of Resident 14's progress notes dated December 11, 2023, revealed 2.5cm x 2cm open area noted on residnets left testicle during HS care. Zicn oxide ointment applied. Will continue to monitor. Review of Resident 14's care plan failed to reveal evidence that a care plan was established regarding the above-mentioned wound. Interview with the Nursing Home Administrator and Director of Nursing on February 1, 2024, at 10:15 a.m. confirmed the facility did not have a care plan for Resident 14's wound. 28 Pa. Code 211.11(a)(b)(c)(d)(e) Resident care plan Previously cited 5/13/2023 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 8 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 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 the clinical record and interviews with staff it was determined that the facility failed to follow physician orders for one of 24 residents reviewed ( Resident 59). Residents Affected - Few Findings include: Review of Resident 59's clinical record revealed physician orders on June 15, 2023, for HumaLOG KwikPen Solution Peninjector 100 UNIT/ML (Insulin Lispro (1 Unit Dial)) Inject 8 unit subcutaneously three times a day for diabetes Hold if BS (blood sugar) < (less than) 110, for diabetes. Review of the Medication Administration Records (MAR) revealed the resident was given insulin when the blood sugars were below 110: October 11 (89), October 16 (108), November 17 (104), December 12 (84), January 11 (94), and January 28 (108). An interview with the Nursing Home Administrator and Director of Nursing was conducted on February 1, 2024, at 9:35 a.m., revealed that the insulin should not have been administered on the dates mentioned above for Resident 59. 28 Pa. Code 201.18(b)(1) Management 28 Pa. 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 9 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and interviews with staff, it was determined that the facility failed to ensure that one of two residents (Resident 50) reviewed for pressure ulcers was monitored, assessed and received the necessary services to prevent new ulcers from developing, resulting in actual harm of pressure ulcer development for Resident 50. Residents Affected - Few Findings include: Review of Resident 50's diagnosis list revealed diagnoses including; Metabolic Encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), Muscle Weakness (reduction in the power exerted by muscles resulting in an inability to perform a given task), Cognitive communication deficit (difficulty with communication that is caused by a problem with thinking). Review of Resident 50's comprehensive assessment Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) Dated November 15, 2023, revealed that Resident 50 had no skin impairment. Additionally the MDS revealed Resident 50 has a BIMS (Brief Interview for Mental Status- used to assess cognitive status in elderly) of 00 (indicating severe impairment). Review of Resident 50's care plan dated November 11, 2023, revealed the following focus areas: Resident 50 has potential for pressure ulcer development regarding to impaired mobility, Resident 50 has potential/actual impairment to skin integrity issues regarding to a history of cellulitis (bacterial skin infection), Resident 50 exhibits behaviors such as picking at the skin creating/enlarging wounds and MASD (Moisture-Associated Skin Damage) to sacrum. Additional review of Resident 50's care plan revealed the following interventions: Keep skin clean and dry. Use lotion on dry skin. Do not apply to open areas initiated date of April 18, 2023. Encourage good nutrition and hydration in order to promote healthier skin, initiated date of April 18, 2023. Observe for/document breaks in skin and notify MD (Medical Doctor), initiated date of April 18, 2023. Pressure reduction mattress to prevent skin breakdown as ordered initiated date of April 18, 2023. Observe for/document breaks in skin and notify MD, initiated date of April 18, 2023. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) etc. to MD initiated date of November 22, 2023. Review of Resident 50's clinical record revealed a weekly skin assessment dated [DATE], at 2:47 p.m. indicating Resident 50 had MASD Damage (inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, or sweat) located on Resident 50's sacrum (triangular bone at the base of the spine) which resolved (healed) on January 2, 2024. Review of the facilities wound tracking logs revealed Resident 50's Stage 4 pressure injury was first observed on January 9, 2024. Review of information provided by Director of Nursing revealed Resident 50's weekly skin assessment dated [DATE], stating, Skin Condition: Skin intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 10 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 Review of Resident 50's initial wound evaluation and management summary dated January 16, 2024, by wound specialist physicians revealed the following wound measurements 0.5 x 0.5 x 0.3 cm (centimeters). Level of Harm - Actual harm Residents Affected - Few Further review of Resident 50's clinical medical record revealed a Dietitian progress note dated January 18, 2024, at 5:12 p.m. indicating, Aware of resident with a stage 4 pressure injury (break in the skin that extending through the muscle and bone) on sacrum. On February 1, 2024, at 10:50 a.m. the surveyor asked the Director of Nursing regarding any investigation into Resident 50's stage 4 pressure injury. The Director of Nursing was unable to provide investigation documentation. Additional review of Resident 50's clinical record failed to reveal additional documentation of the Stage 4 pressure injury. Interview conducted with the Director of Nursing (DON) on February 1, 2024, at 10:10 a.m. reported Resident 50 tested positive of COVID-19 which resulted in Resident 50 becoming lethargic (sluggish) staying in bed all day and refusing to eat. The Director of Nursing reported that Resident 50's COVID-19 symptoms resulted in Resident 50 developing a stage 4 pressure injury due to staying in bed and refusing to eat for multiple days. Review of Resident 50's clinical medical record revealed a progress note dated January 8, 2024, at 10:09 a.m. stating resident presents with increased congestion (stuffy nose) and productive cough (wet cough). covid test positive. verified by RN supervisor. Review of Resident 50's electronic treatment administration record (eTAR) revealed an order for House barrier cream (reduces friction and irritation of the skin), every shift for prevention Apply bilateral buttock, peri area and sacrum with care, nurse aide may apply, may keep at bedside with a start date April 18, 2023. Additional review of Resident 50's eTAR revealed the barrier cream was documented as applied to Resident 50's sacrum January 1, 2024, through January 29, 2024, for each morning, evening, and night shift but failed to reveal documentation related to Resident 50's stage 4 pressure injury. Review of Resident 50's care plan failed to reveal new interventions initiated after the discovery of the stage 4 pressure injury on January 9, 2024. The above information was conveyed to the Nursing Home Administrator and Director of Nursing during an interview on February 1, 2024, at approximately 11:31 a.m. The facility failed to identify, assess and monitor skin integrity and develop and implement a plan of care to prevent pressure ulcers from developing on the sacrum of Resident 50, resulting in actual harm for this resident. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(3) Nursing Services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 11 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 211.12(d)(5) Nursing Services Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 12 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, it was determined the facility failed to properly label insulin pens and vials with open and expiration dates for four of four medication carts observed (First floor medication carts and Second Floor medication carts). Findings include: Observation on [DATE], at 11:30 a.m. of the first Second Floor medication cart revealed one open Basaglar Insulin pen with no open or expiration date on the label. Further observation of the first Second Floor medication cart revealed one open Humalog Insulin Pen with an open date of [DATE]. This insulin pen expired [DATE]. Observation on [DATE], at 11:45 a.m. of the First Floor Back Hall medication cart revealed two open Lispro Insulin Pens with an open date of [DATE], and no expiration date. This insulin expired [DATE]. Further observation of the First Floor Back Hall medication cart revealed a Lantus Insulin pen with no open date. Observation on [DATE], at 11:50 a.m. of the First Floor Front Hall medication cart revealed one open Lispro Insulin vial with no open date; two Lantus Insulin pens with no open date; one Humalog Insulin pen with an open date of [DATE], with an expiration sticker indicating expiration on [DATE]. The actual expiration date of the Humalog Insulin should have been [DATE]. Further observation of the First Floor Front Hall medication cart revealed two open Lispro insulin pens with no open date. Interview with the Nursing Home Administrator and the Director of Nursing on February 1, 2024, conveyed the above-mentioned information regarding unlabeled and expired medication. 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 211.12(c)(1)(2)(3)(5) Nursing Services Previously cited [DATE] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 13 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that diagnostic services were provided in a timely manner to meet the needs one of 24 residents reviewed. (Resident 62). Residents Affected - Few Findings include: Review of Resident 62 clinical record revealed a progress note dated December 15, 2023, which revealed, the resident presented with a productive cough and wheezing presented in (both) lobes on expiration. Resident 02 (oxygen) is 95 on RA (room air). This nurse notified the physician. New orders include Ipratropium-Albuterol Solution QID X3 days (an inhaler) and Chest X-ray 2 views. The diagnostic company was called, and confirmation number obtained. On December 15, 2023, the diagnostic company called and stated that they will not be able to get her today for the ordered x-ray but will be in the following day. On December 16, 2023, the facility phoned the diagnostic company and asked when they planned to do x-ray on this resident, the receptionist apologized and stated that she could not provide the exact time because they are very busy at the moment. A call later that evening from the diagnostic company stated that they will not be in to do X-ray as ordered and that they will be in the following day. This is the second day they have cancelled. Further investigation revealed that the x -ray was completed on December 17, 2023. Interview with the Nursing Home Administrator and Director of Nursing, on February 1, 2024, at 9:30 a.m., confirmed that the facility did not ensure that diagnostic services were provided in a timely manner to meet the need of Resident 62. Pa. Code: 211.12(b) Nursing services Pa. Code: 211.12(d)(1)(3) (5) Nursing services Pa. Code: 211.10(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 14 of 15 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 395575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to maintain infection control practices to prevent spread of infection for one of 24 sampled residents. (Resident 52). Residents Affected - Few Findings include: Interview conducted with the Nursing Home Administrator (NHA) on January 29, 2024, at 9:03 a.m. revealed Resident 52 tested positive for COVID-19 on January 19, 2024, and was subsequently placed on contact precautions (precautionary measures used while caring for residents with infections, diseases, or germs that are spread by touching the resident or items in the resident's room) on January 19, 2024. Observations conducted on January 29, 2024, at 9:20 a.m. revealed Resident 52 did not have any PPE (personal protective equipment) stationed outside the room door. Further observation noted absence of signs on the resident's door indicating PPE required to enter Resident 52's room. Interview conducted with the infection preventionist coordinator (IPC) on January 31, 2024, at 1:50 p.m. confirmed PPE should be present outside Resident 52's room along with signs indicating Resident 52 is on contact precautions and PPE is required to enter the room. The above information was conveyed to the Nursing Home Administrator and Director of Nursing in an interview on January 31, 2024, at approximately 1:55 p.m. 28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395575 If continuation sheet Page 15 of 15