Health inspection·December 18, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete solarium sidewalk and the employee entrance and proceeds to walk to the employee entrance area and enter the building. Video footage at 10:31 a.m. revealed three facility staff running from the direction of the SSW solarium doors towards Resident R1 who was walking in the far front corner of the rear employee parking lot. Video footage at 10:33 a.m. revealed a facility staff member in a red hoodie seen walking from the employee parking lot to the employee entrance and Resident R1 and the three staff seen passing in front of the employee in the red hoodie walking back toward the SSW solarium doors. Video footage at 10:33 a.m. revealed Resident R1 and three facility employees approaching the area of the solarium doors. During a follow-up interview on 12/16/25, at approximately 12:19 p.m. the NHA confirmed that he/she was aware of Resident R1's elopement from the facility on 12/9/25 and failed to conduct an investigation of the elopement. 28 Pa. Code 201.18 (e)(1)(2) Management28 Pa. Code 201.29 (a)(c) Resident Rights28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services Event ID: Facility ID: 395793 If continuation sheet Page 2 of 7 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 395793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Manor 20 Orchard Drive Grove City, PA 16127 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policy and documentation, and staff and resident interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for one of two residents reviewed who eloped from the facility (Resident R1). Findings include: Review of facility policy entitled, Safety and Supervision of Residents dated 4/1/25, indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our facility-oriented approach to safety address risks for groups of residents. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting process; Quality Assurance and Performance Improvement (QAPI) reviews of safety and incident/accident date; and a facility-wide commitment to safety at all levels of the organization. Review of facility policy entitled, Wandering and Elopements dated 4/1/25, indicated When the resident returns to the facility, the director of nursing or charge nurse shall: examine the resident for injuries; contact the attending physician and report findings and conditions of the resident; notify the resident's legal representative; complete and file an incident report; document relevant information in the resident's medical record. Resident R1's clinical record revealed an admission date of 3/28/2025, with diagnoses that included Dementia (loss of memory, language, problem-solving, and other thinking abilities), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure. A Minimum Data Set (MDS-a periodic assessment of resident care needs) Section C Cognitive Patterns dated 10/30/2025, identified Resident R1 with a Brief Interview for Mental Status (BIMS-a type of test to determine one's level of cognition) score of 11 and moderately impaired. Review of Resident R1's MDS Section E Behaviors dated 10/30/2025, revealed under section

E0900 wandering presence and frequency- Has the resident wandered? with response of 2-Behavior of this type occurred 4-6 days. Review of an Elopement Risk Assessment completed on 4/15/25, indicated Resident R1 had an elopement score of 11. High Risk to Wander. During an onsite investigation on 12/15/25, it was identified that Resident R1 had eloped from the dementia unit of the facility on 12/09/25. Review of Resident R1's clinical record lacked any documentation on 12/9/2025, regarding the elopement until the investigation on 12/16/25. Review of Resident R1's care plans revealed no updates to care plans regarding elopement risk from the date of the elopement on 12/9/25, to investigation on 12/15/25. During an initial interview on 12/15/25, at approximately 9:00 a.m. the Director of Nursing (DON) revealed that he/she was unaware of any elopements or close calls since April 2025, which the facility investigated and reported as required. DON stated that he/she was on vacation last week and just returned this morning. DON stated that the Nursing Home Administration is scheduled to return from vacation tomorrow. Interview with Maintenance Supervisor on 12/15/25 at 11:00 a.m. revealed that he/she heard that there was an elopement last week on the locked unit, Sunshine Way (SSW), but didn't know any details and was not asked to check any door locks in the facility last week or this week. He/she stated all doors and door alarms are checked monthly and were last inspected on 12/1/25. During interviews on 12/15/25, Nursing Assistant (NA) Employee E3 and E4, Licensed Practical Nurse (LPN) Employees E5, E6, E 8, and E11, and Housekeeping Employees E7, and E9 revealed he/she were unaware of an elopement or elopement drill at the facility last week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395793 If continuation sheet Page 3 of 7 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 395793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Manor 20 Orchard Drive Grove City, PA 16127 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview with NA Employee E1 on 12/15/25 at 11:30 a.m. revealed that he/she was working on SSW 12/9/25. At approximately 10:30 a.m. the door alarms sounded and he/she walked to the nursing station to check to see where the alarm triggered. He/she stated it was the solarium doors in Sunshine Way. NA Employee E1 went to check the doors in the dining area and found the doors locked without any visible tracks in the snow outside the door. NA Employee E1 then went to the kitchen door in SSW and found the doors locked without any tracks visible in the snow outside the door, then proceeded down the hall to the solarium where the RN supervisor, an LPN, and a NA were already looking out and saw Resident R1 walking in the parking lot that was located up a sidewalk and a distance from the exit door of SSW. The RN supervisor unlocked the solarium doors and NA Employee E1 ran through the back parking lot and was able to talk the resident into walking back to the unit. He/she stated the resident was wearing a gray hoodie with the hood up, jeans, tennis shoes and socks. The resident told staff he was cold but denied any injuries. NA Employee E1 stated he/she was not asked to complete an incident report. During an interview on 12/15/25, the Activity Director revealed that on 12/9/25, he/she heard a Code W (the facility alert for an elopement) on the walkie talkie and immediately went to Unit B to check on residents. He/she stated then found out it was for Sunshine Way and was identified as a drill. Interview with the Assistant Director of Nursing (ADON) on 12/15/25, revealed that he/she stated there was an elopement drill last week on Sunshine Way, but no actual elopement. He /she stated the NHA wanted to have a drill, so Resident R1 from Sunshine was chosen as he was steady on his feet. ADON stated the NHA wanted to have an outside drill as it wasn't very cold out that day and the sidewalk was clear. ADON stated Employee E15 assisted by unlocking the doors in Sunshine Way by the solarium, stepped away from the doors into the solarium and let the Resident out the doors onto the sidewalk. ADON stated that he/she was in that area watching from the back door at the employee entrance and that the resident walked approximately to the end of the sidewalk by the dumpsters, the alarms sounded as expected, staff from the unit immediately found the resident and returned him to Sunshine Way. The ADON states that Resident R1 was also seen by Employee E16 during the drill from the window of room [ROOM NUMBER]. During interviews on 12/15/25, LPN Employees E12 and E13 revealed there was an elopement drill at the facility on 12/9/25. Interview on 12/16/25 at 8:45 a.m. with the NHA revealed that the facility conducted an elopement drill last week on SSW. Interview with NA Employee E2 12/16/25, at 9:09 a.m. revealed that he/she was working 12/9/25 in Sunshine Way and the door alarms sounded. He/she went to the solarium doors and saw Resident R1 walking in the employee parking lot at the back of the building. He/she stated staff went out and brought him back into the building. He/she stated that the solarium was cleaned on 12/8/25, with strong chemicals and the solarium doors were open for a while to air it out. He/she stated that the doors must not have locked properly. He/she stated that no one from the facility asked him/her to complete an incident report or sign anything. Interview with LPN Employee E16 on 12/16/25, at 9:30 a.m. revealed that on 12/9/25, he/she was walking in the back parking lot to the employee entrance around 10:30 a.m. He/she saw a man walking with jeans and a hoodie up by the dumpsters but thought it was one of the maintenance employees. He/she stated that when they got inside, heard the alarms and walked to SSW. He/she stated they do not remember seeing anyone else outside at the time but couldn't say for sure. He/she stated that no one from the facility asked him/her to complete an incident report or sign anything. Interview with LPN Employee E15 on 12/16/25, at 11:30 a.m. revealed that he/she was walking on Unit A when the door alarms went off. He/she walked to Unit B to check those doors as everything was secure on Unit A. He/she stated while on Unit B, that he/she received a call from ADON that the alarm had sounded on Sunshine Way and that staff got Resident R1 from outside. LPN Employee E15 then walked to SSW and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395793 If continuation sheet Page 4 of 7 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 395793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Manor 20 Orchard Drive Grove City, PA 16127 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the resident was back inside by that point. He/she stated later was told by the NHA that it was a drill. He/she was not asked to complete any paperwork after, except to sign an elopement drill sign-in sheet. During a follow up interview with the NHA 12/16/25, at 12:19 p.m. revealed that he/she was in the NHA office sitting with the facility owner when he/she received a call that Resident R1 got out the solarium doors in SSW but that Resident R1 was only out a few steps. NHA stated he/she was unable to remember who called and supplied that information. He/she went to SSW right after the call and Resident R1 was back inside and ok and was told that LPN Employee E16 had eyes on him/her the whole time and as was always visible, treated the elopement as a drill. NHA confirms that the elopement on 12/9/25 was not investigated. During a follow up interview on 12/16/25, at 12:30 p.m. the ADON, confirmed Resident R1 eloped from the facility on 12/9/25 and there was no evidence that the facility examined the resident for injuries; contacted the attending physician and reported findings and conditions of the resident; successfully notified the resident's legal representative; completed and filed an incident report; investigated or documented relevant information in Resident R1's clinical record. Review of video footage on 12/16/25, supplied by the facility of the rear camera that captured the sidewalk for SSW solarium doors, the employee entrance, and rear employee parking lot revealed that on 12/9/25 at 10:29 a.m. Resident R1 is seen walking alone on partially snow-covered sidewalk from the direction of the solarium doors toward the rear employee parking lot. Resident R1 was wearing a hoodie, jeans, and shoes. As Resident R1 was walking, he/she put the hood of his/her hoodie up. At 10:30 a.m., a facility staff member is seen walking from his/her car to the rear employee entrance and Resident R1 is within view of this employee near the facility dumpsters. Video footage at 10:30 a.m. revealed an employee walking from a fenced area at the back of the facility between the solarium sidewalk and the employee entrance and proceeds to walk to the employee entrance area and enter the building. Video footage at 10:31 a.m. revealed three facility staff running from the direction of the SSW solarium doors towards Resident R1 who is walking in the far front corner of the rear employee parking lot. Video footage at 10:33 a.m. revealed a facility staff member in a red hoodie seen walking from the employee parking lot to the employee entrance and Resident R1 and the three staff seen passing in front of the employee in the red hoodie walking back toward the SSW solarium doors. Video footage at 10:33 a.m. revealed Resident R1 and three facility employees approaching the area of the solarium doors. Immediate Jeopardy (IJ) was identified 12/16/25 at 2:45 p.m. to the NHA and DON and the IJ template was provided to the NHA at that time, related to resident safety/elopement. The NHA and DON were made aware that the Immediate Jeopardy existed for the failure to take appropriate safety actions/investigation after the event to ensure safety of all residents at the facility and an immediate action plan was requested. On 12/16/25, at 4:25 p.m. an acceptable immediate action plan was approved which included the following interventions:1. All secured exit doors were checked and confirmed to be fully operational. Director of Nursing reinforced that secured doors may not be propped open for any reason. This expectation was communicated to all departments, including housekeeping and maintenance, effective immediately.2. The resident involved and all residents residing on the secured unit were reassessed for elopement risk, and care plans were reviewed and updated as indicated. A head-to-toe skin assessment was completed on the resident involved with no findings. Any resident identified as high risk is subject to hourly documented supervision for a minimum of twenty-four hours, with continued monitoring based on reassessment.3. Effective immediately, the facility will implement hourly documented checks for 24 hours following any cleaning, construction, or maintenance activity involving secured exits to ensure doors remain secured and alarms are active.4. All in-house staff will be educated by the Director of Nursing or designee by 5:00 p.m. today on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395793 If continuation sheet Page 5 of 7 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 395793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Manor 20 Orchard Drive Grove City, PA 16127 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility's elopement policy, elopement prevention, door alarm response expectations, supervision requirements, and escalation procedures for any alarm activation involving secured exits. All remaining staff will be educated prior to the start of their next scheduled shift until one hundred percent of staff education is completed. Any staff member on vacation or otherwise unavailable in person will be educated by telephone. No staff member will be permitted to work until education has been completed. Compliance will be monitored by the Director of Nursing or designee.5. The Director of Nursing or designee is actively monitoring elopement risk mitigation through daily review of door alarm functionality, alarm response, and supervision compliance. Any identified concerns are addressed immediately. After review of facility documentation, observations, and staff interviews, the implementation of the above stated action plan was confirmed on 12/17/2025, at 4:12 p.m. and the NHA and DON was informed that the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing Services Event ID: Facility ID: 395793 If continuation sheet Page 6 of 7 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 395793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Manor 20 Orchard Drive Grove City, PA 16127 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) failed to effectively manage the facility to make certain that proper supervision and elopement prevention were effectively implemented in the facility. Findings include: Review of the job description for the NHA revealed The administrator is charged with the general administration of the facility; Manage subordinate supervisors who supervise all employees in all departments; Responsible for the overall direction, coordination, and evaluation of these units; and directly or through delegation, carries out supervisory responsibilities in accordance with the facility's policies and applicable laws. Based on the findings in this report that identified the facility failed to consistently supervise and maintain all safety interventions to prevent elopement for their residents, the NHA failed to fulfill their essential job duties to ensure that the Federal and State guidelines and Regulations were followed. Refer to F689 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395793 If continuation sheet Page 7 of 7