Health inspection·August 7, 2023

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/10/36 I observed him scratching and bleeding many times due to medication Eliquis. I've cared for him with bleed bruising and swelling months ago. During interview with facility Nursing Home Administrator, Employee E1, on August 7, 2023, at 10:17 a.m. Employee E1 stated, the aids were saying maybe he wasn't holding on tight to his transfer machine and confirmed that the facility failed to conduct interviews or statements regarding a [NAME] of unknown origen. Interview with the Assistant Director of Nursing, Employee E3, on August 7, 2023, at 11:45 a.m. confirmed there were no bruising identified and documented, in Nurse Aid [NAME] documentation tab, for the entire months of May and June 2023, prior and post incident. Further interview with Employee E3 at 11:58 a.m. confirmed that a skin check after the reported incident, dated June 5, 2023, was not documented and that the Resident R35's area of injury was not assessed. 28 Pa. Code 201.14(a)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 2 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for hearing difficulty and scratching behaviors for two of 21 residents reviewed (Resident R8 and R35). Findings include: A review of the facility policy titled, Individualized Care Plan, revised October 20, 2022, revealed, the IDT develops comprehensive care plan addressing the residents most acute problems. The comprehensive care plan will include services that are to be furnished to attan or maintain the residents highest practicable physical, mental and psychological well-being. During resident screening conducted on August 2, 2023, on the second floor, at approximately 12:28 p.m. revealed Resident R8 sitting in her room at bedside. Surveyor greeted Resident R8 at the door but Resident R8 did not look up. After several greeting attempts, each attempt louder than the previous, resident still had not acknowledged surveyor due to hard of hearing. A review of Resident R8's Minimum Data Set (MDS-periodic assessment of resident care needs) dated March 26, 2023, Brief Interview for Mental Status Score (BIMS), Resident R8 had a score of 15, indicating that the resident's cognition was intact. Further review of MDS dated [DATE], under the section, BO200 Hearing, revealed resident had minimal difficulty with hearing. Further review of Resident R8's admission Packet dated, June 9, 2023, revealed resident is hard of hearing making it more difficult to communicate. Review of admission progress note dated, June 9, 2023, revealed resident is hard of hearing, no hearing aids. Interview with Resident R8 on August 4, 2023, at 12:29 p.m. revealed resident cannot hear in right ear. Resident stated, it feels clogged and I hear noises. Further interview revealed resident's son bought her hearing amplifiers which really help. Interview with Licensed Practical Nurse, Employee E8, revealed that Resident R8 cannot hear and that you need to come really close to her for her to speak. Further observations revealed Employee E8 was very close to the resident's ear when inquiring abut residents hearing amplifiers. Interview with the Director of Nursing on August 4, 2023, at 2:11 p.m. confirmed Resident R8 has headphones to amplify hearing. Further interview revealed that the hearing amplifiers were supplied by the Resident's son. Further interview with Social Services, Employee E7, revealed resident needed to wear hearing amplifiers during the care conference held on July 13, 2023. Review of Resident R8's clinical record revealed no documented evidence a comprehensive care plan was developed for Resident's R8 hearing difficulties and communication. During an exit interview with the Administrator on August 4, 2023, at 3:36 p.m. Employee E1 stated Resident R8 should have been care planned for her hearing. Review of Resident R35's MDS dated [DATE], revealed resident was admitted to the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 3 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 Residents Affected - Few [DATE], with diagnoses including Dementia (condition that affects the brain's ability to think, remember, and function). Review of Resident R35's BIMS revealed a score of six, indicating severely impaired cognition. Review of resident's clinical record revealed resident was experiencing scratching behaviors. Review of facility investigation report for Resident R35 revealed a statement by nurse aide, Employee E9, which confirmed Resident R35 is known for scratching himself till he bleeds. Review of another statement by Employee E10 revealed, I observed him scratching and bleeding many times. Review of weekly skin check documentation notes revealed the following: Skin check dated, January 23, 2023, revealed, scratches noted throughout resident arms, and stomach. Skin check dated, March 13, 2023, revealed, resolving scratches and small scabs to arms and upper legs and chins. Skin check dated, June 26, 2023, revealed, small scratches to sacrum. Skin check dated, July 3, 2023, and July 17, 2023, revealed, back is noted to have some scratches. Review of resident R35's clinical record revealed no documented evidence a comprehensive care plan was developed for Resident's R35's scratching behaviors. Interview with Director of Nursing, Employee E2, and Administrator, Employee E1, on August 7, 2023, at approximately 12:30 p.m. confirmed the above findings. 28 Pa. Code 211.10 (a) Resident Care Policies 28 Pa. Code 211.10 (d) Resident Care Policies 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 4 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a complete discharge summary was completed for two of three closed records reviewed (Resident R154 and R48). Findings Include: Review of Resident R154's clinical record revealed the resident was discharged to the hospital on [DATE], and did not return to the facility after hospitalization. Review of Resident R48's clinical record revealed the resident expired at the facility on [DATE]. Further review of the clinical records revealed no documented evidence that the physician completed a discharge summary with a recapitulation of the resident's stay at the facility. Interview on [DATE], at 1:50 p.m. with Employee E1, Nursing Home Administrator, confirmed discharge summaries were not available for Resident R154 and R48. 28 Pa. Code 211.5 (d) Medical Records 28 Pa. Code 211.5 (f) (xii) Medical Records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 5 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews with staff, it was determined that the facility failed to obtain physician orders for one of 14 records reviewed for monitoring of a medication. (Resident R39). Residents Affected - Few Finding include: Review of Resident R39's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated April 4, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including hypertension (high blood pressure) and congestive heart failure (heart is not able to pump blood efficiently so blood and fluids collect in your lungs and legs over time) and atrial fibrillation (irregular heart beat because blood not flowing proper in heart causing an increase in blood clot and increase of stroke). Review of Resident R39's physician orders instructed to obtain daily weights dated April 1, 2023 and Digoxin Oral Tablet 250 mcg, give 0.5 tablet by mouth one time a day related to atrial fibrillation. On April 3, 2023 the order changed to Digoxin oral tablet, 250 mcg give 0.5 tablet by mouth one time a day and to check Apical (heart) pulse; hold if less than 60/min. Review of Resident R39's care plan for congestive heart failure dated April 1, 2023 revealed interventions that included daily weights (one of first symptoms of CHF is when the heart does not pump sufficiently causing weight gain), to observe, report, document any adverse reactions of digoxin therapy, and to obtain Serum digoxin levels as ordered. Nursing progress note dated May 9, 2023, indicated Resident R39 was given IV fluids (intra venous) due to elevated BUN of 99 (blood urea nitrogen normal levels are between about 7 and 20 milligrams per deciliter (mg/dL). and Cr 2.0 (creatine levels normal in men are between 0.7 to 1.3 mg/dL) related to the resident's poor intake of meals. The same day the resident was admitted to the hospital due to critical labs. Review of Resident R39 hospital discharge summary of hospitalization, dated May 15, 2023, revealed Resident R39's Digoxin was discontinued during his hospital stay due to high levels on admission, noting, Concern for toxicity given poor oral intake and abnormal kidney function. On August 7, 2023, at 9:54 a.m. the surveyor requested documentation for review of Resident R39's labs for monitoring digoxin levels and toxicity. The Director of Nursing stated All residents on Digoxin have labs. There was no evidence that the facility obtain or requested labs to ensure monitoring of Resident R39 digoxin levels prior to his hospitalization. 28 Pa. Code 211.12 (c) Nursing services 28. Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 6 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, resident and staff interviews, it was determined that the facility failed to monitor hydration and nutritional supplement consumption for two of three residents reviewed for nutritional status. (Resident R22, and Resident R39) Residents Affected - Few Findings include: Review of facility policy Nutrition and Weight Management Program in the section titled, Oral supplements, revealed Oral nutritional supplements such as Ensure and Boost are used as an intervention for nutritional supplementation. Staff is to monitor the resident's intake of supplements. Review of Resident R22's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated June 8, 2023, revealed that the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's Dementia (a disease that destroys memory and other important mental functions). A review of Resident R22's BIMS (Brief Interview of Mental Status) revealed a score of ten, which indicated that the resident had moderately impaired cognition. Review of R22's clinical records revealed Resident R22 had a documented weight of 137.6 pounds on March 7, 2023, and a weight of 130.5 pounds on June 6, 2023; indicating a significant weight loss of 5% weight loss in three months. Further review revealed a documented weight of 158 pounds on December 7, 2022, and a weight of 130.5 pounds on June 6, 2023; indicating a significant weight loss of 17.4% in six months. Review of physician orders revealed an order dated June 15, 2023, for a dietary supplement, Ensure, three times a day for supplement nursing to provide and document percentage consumed. Review of Resident R22's Medication Administration Records for June, July, and August, 2023 revealed documented evidence that the nutritional supplement had been provided to resident but no documented evidence of supplement daily percent intakes by resident. Further review of progress notes revealed no documented evidence regarding an alternative supplement option choice offered to resident when resident had refused the Ensure nutritional supplement. Interview with the Registered Dietitian, Employee E6, on August 4, 2023, at 1:52 p.m. revealed Resident R22 had a history of refusing meals and prefers to eat in her room. Further interview confirmed there was no documented evidence of supplement daily percent intakes by resident to be able to evaluate the effectiveness of this nutrition intervention. Employee E6 stated that the nursing staff was responsible to document percent daily intakes my resident. During an interview with Employee E6, on August 4, 2023, at 3:02 p.m., Employee E6 confirmed failure to monitor nutritional supplement consumption for Resident R22, it should have been documented. Review of Resident R39's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated April 4, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including hypertension (high blood pressure) and congestive heart failure (heart is not able to pump blood efficiently so blood and fluids collect in your lungs and legs over time) and atrial fibrillation (irregular heart beat because blood not flowing proper in heart causing an increase in blood clot and increase of stroke). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 7 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R39's physician order instructed to administer, Furosemide Oral Tablet 40 milligrams (mg) a day (a diuretic used for fluid retention) on April 1, 2023. On April 24, 2023, the resident's Furosemide Oral Tablet 40 mg was changed to two times a day. Further review of Resident R39's physician order instructed on April 1, 2023 give Digoxin Oral Tablet 250 mcg, administer 0.5 tablet by mouth one time a day related to atrial fibrillation. On April 3, 2023 the order changed to Digoxin oral tablet, 250 mcg give 0.5 tablet by mouth one time a day and to check Apical (heart) pulse; hold if less than 60/min. Nursing progress note dated May 9, 2023, indicated Resident R39 was given IV (intra venous) fluids due to elevated BUN of 99 (blood urea nitrogen normal levels are between about 7 and 20 milligrams per deciliter (mg/dL). and Cr 2.0 (creatine levels normal in men are between 0.7 to 1.3 mg/dL) related to the resident's poor intake of meals. The same day the resident was admitted to the hospital due to critical labs. Review of Resident R39's hospital discharge summary of hospitalization, dated May 15, 2023, revealed Resident R39 was diagnosed with chronic kidney disease ( CKD not previously diagnosed during facility admission). Hospitals assessment and plan for Resident R39's renal insufficiency at discharge stated, Progressively worsening renal function over the last month or so in the setting of dehydration most likely he has known chronic renal disease somewhere in the II-III range. Assessment and plan for chronic heart failure was to hold diuretics since the resident was currently hypovolemic (loss of body fluid and blood. Elevated troponin assessment and plan stated to be acute myocardial injury in the setting of progressively worsening renal function, and hypovolemia). Continue review of the hospital discharge instructions revealed Resident R39's Digoxin level was also discontinued during his hospital stay due to high levels on admission, Noted, Concern for toxicity given poor oral intake and abnormal kidney function. Review of Resident R39's care plan revealed interventions dated March 31, 2023, were in place on admission to observe, document or report signs of dehydration due to using a diuretic, to monitor, observe, record and report changes in meal intake, and to observe, report, document any adverse reactions of digoxin therapy, and to obtain Serum digoxin levels as ordered. Progress note dated, April 11, 2023, revealed prior to Resident R39's hospital admission the Dietary/Nutritionist was made aware by nursing and dining services Resident R39 was declining his meals and supplements. Prior to Resident R39's hospitalization, noting his decrease intake in meals his medication administration record revealed the resident continued to receive his diuretic and digoxin. Further review of Resident R39's clinical record revealed no documented evidence the facility was recording his fluid intakes, nor were serum digoxin levels obtained. Interviews with the Director of Nursing on August 4, 2023, at 3:00 p.m. confirmed Resident R39's fluid intake was not recorded and stated We only write down the amount of food they eat, not what they drink On August 7, 2023, at 9:54 a.m. the surveyor requested to review Resident R39's labs for monitoring digoxin toxicity and the Director of Nursing stated All residents on Digoxin have labs. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 8 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 0692 requested labs were not received nor any documented evidence the facility was monitoring Resident R39 digoxin levels prior to his hospitalization. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.5 (f) Clinical records Residents Affected - Few 28 Pa. Code 211.6 (d) Dietary services 28 Pa. Code 211.12 (c)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 9 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of resident records and facility policy, it was determined that the facility did not ensure one resident receiving respiratory care was provided care consistent with professional standards of practice for one of two residents reviewed receiving respiratory services (Resident R25). Residents Affected - Few Findings include: Facility policy titled Oxygen Administration not dated stated, Oxygen is administered to residents who need it consistent with professional standards of practice. Review of Resident R25's clinicakl record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of acute respiratory failure and used supplemental oxygen to assist in breathing. Physician orders dated May 2, 2023, instructed to Wean oxygen to keep SATS (oxygen saturation) above 90%. On August 2, 2023, at 11:29 a.m. with Licensed Nurse, Employee E5, Resident R25 was observed on 3 liters (L) of oxygen at bedside. Employee E5 stated she didn't know why it was on 3 L of oxygen, It's been that way. On August 2, 2023, at 1:49 p.m. the Director of Nursing confirmed the number of liters was not specified in Resident R25's orders and should be on 2 liters of oxygen. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 10 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on review of facility documentation, clinical records review, and staff interview, it was determined the facility failed to ensure an as needed psychotropic medication had documented rationale for continued use past 14 with a duration for the PRN order, failed to appropriately monitor the effects of the medication, and failed to administer the medication in accordance with prescriber recommendations for one of five residents reviewed for medication regimen reviews (Resident R28). Findings Include: Review of Resident R28's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 29, 2023, revealed the resident had a diagnosis of anxiety disorder (intense, excessive, and persistent worry and fear) and received antianxiety medications during the last seven days. Review of Resident R28's comprehensive care plan dated December 28, 2022, revealed the resident used anti-anxiety medications related to anxiety disorder. Interventions included to monitor/document/report any adverse reactions to anti-anxiety therapy. Review of Resident R28's psych evaluation dated June 23, 2023, by Psych Certified Registered Nurse Practitioner (CRNP), Employee E12, revealed the prescriber recommended Ativan 0.5 milligrams (mg) at 4:00 p.m. and Ativan 0.5 mg at 8:00 p.m. for anxiety. Review of Resident R28's physician order summary revealed orders dated March 21, 2023, for Ativan 0.5 mg at 5:00 p.m. daily, and Ativan 0.5 mg at 7:00 p.m. daily, subsequently being given only two hours apart as opposed to four hours apart per the prescriber recommendations. Further review of Resident R28's physician orders revealed an order dated December 29, 2022, to monitor anti-anxiety medication for drowsiness, slurred speech, dizziness, nausea, and aggressive/impulsive behavior. Physician orders indicate that staff should Y if monitored and none of the above was observed and to document N if monitored and any of the above was observed, and to further develop a progress note of findings. Review of Resident R28's August 2023 Medication and Treatment Administration record revealed staff documented N for anti-anxiety medication monitoring for 15 out of 19 shifts but failed to document the side effects Resident R28 was experiencing. Interview on August 7, 2023, with the Director of Nursing, Employee E2, confirmed that the physician order for Ativan is ordered to be given two hours apart as opposed to four hours apart as recommended by the prescriber. Further interview confirmed the staff's failure to accurately document any side-effects from use of the anti-anxiety medication. Continued review of Resident R28 s physician orders revealed the resident also had an order dated March 10, 2023, for Lorazepam (also known as Ativan) 0.5 mg every 24 hours as needed (PRN) for anxiety. Review of Resident R28's monthly pharmacy review dated May 23, 2023, by Consultant Pharmacist, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 11 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employee E11, revealed the resident had an order for Lorazepam in place for greater than 14 days. If the medication cannot be discontinued at this time, document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Review of Resident R28's clinical record revealed no documented evidence the facility documented the intended duration of therapy, and the rationale for the extended time period. 28 Pa. Code 211.12 (c)(d)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 12 of 13 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on review of facility documentation and staff interview it was determined that the facility failed to complete an annual review of the facility assessment for any potential resources needed. Findings Include: On August 2, 2023, at approximately 9:45 a.m. during an entrance conference meeting with Employee E1, Nursing Home Administrator, and Employee E2, Director of Nursing, surveyor requested a copy of the facility assessment within four hours per the entrance conference guidelines. A copy of the facility assessment was requested by surveyor again on August 2, 2023, at approximately 2:00 p.m. and on August 3, 2023, at 10:10 a.m. Review of facility assessment provided by the facility on August 3, 2023, at approximately 2:00 p.m. revealed the facility completed an annual review of the facility assessment on August 3, 2023. Review of facility documentation revealed the last annual review of the facility assessment was completed June 7, 2022. Subsequently, the facility assessment was not reviewed for any potential resources neccesary in the last 14 months. Interview on August 7, 2023, at 1:50 p.m. with Employee E1, Nursing Home Administrator, confirmed the facility assessment was not reviewed annually as required. 28 Pa. Code 201.14 (a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395801 If continuation sheet Page 13 of 13