Health inspection·January 12, 2024

F 0605 disturbance, and mood disorder. Level of Harm - Minimal harm or potential for actual harm At the time of the survey ending January 12, 2024, the facility failed to provide a sufficient, documented clinical rationale for initiating the use of the antipsychotic drug. Seroquel, following Resident B1's display of agitation and aggression during the sexual incident with Resident C1. Residents Affected - Few The facility failed to show evidence that a less restrictive alternative treatment was attempted based on an appropriate assessment, care planning by the interdisciplinary team, and documentation of the medical symptoms and use of a less restrictive alternative for the least amount of time possible. The resident's clinical record failed to contain evidence that the facility staff and/or physician had identified, to the extent possible, and addressed the potential underlying causes of Resident B1's behavior such as environmental factors, such as over stimulation. During an interview with the Nursing Home Administrator (NHA) on January 12, 2024, at 1:25 PM, the NHA confirmed that the facility failed to provide documented evidence that the antipsychotic drug was not initiated to most readily control the resident's behavior following the incident with Resident C1 and failed to provide physician documentation that the antipsychotic drug was required to treat the resident's medical symptoms. Refer F656 28 Pa. Code 211.8 (c.1)(1)(e) Use of Restraints. 28 Pa. Code 211.5 (f) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 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 395872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Millville, The 48 Haven Lane Millville, PA 17846 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 clinical records and staff interview it was determined that the facility failed to fully develop and implement person-centered comprehensive care plans to meet the individualized needs of one resident out of six sampled (Resident B1). Findings included: A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with a history of alcohol abuse, adult failure to thrive and major depressive disorder. A review of Resident B1's plan of care initiated May 17, 2022, for the problem of behaviors indicated that the resident had behaviors related to alteration in neurological status due to dementia with specified behaviors that included sexual behaviors, touching female resident, verbally abusive toward staff, exposing his penis dated 1/5/23, and sexually inappropriate behavior dated 1/7/23. Planned interventions to manage Resident B1's behaviors included frequent visual checks as ordered, cueing and reorientation as ordered, and to remove resident from public area when behavior is disruptive/unacceptable. A nursing progress notes dated January 7, 2023, at 1:30 PM, revealed that the resident approached another resident inside the smoking area and stated, I want you now and was placed on supervision by staff when out of his room and when in the smoking due to inappropriate sexual comments/behaviors. An MDS assessment (Minimum Data Set assessment a federally mandated standardized assessment completed periodically to plan resident care) dated November 14, 2023, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 12 (8 to 12 points: suggests moderate cognitive impairment). A review of Resident C1's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia, anxiety, malnutrition, and had a BIMS score 10 or moderate cognitive impairment. A review of a facility incident report dated December 29, 2023, at 11:45 AM, revealed that Employee 1, a nurse aide found Resident B1 in the facility's East TV Lounge seated in his wheelchair, in the front corner of the room, with his pants pulled down to expose his privates (genitals) and Resident C1's (a female resident with moderate cognitive impairment) seated in her wheelchair directly in front of him with her hand on his privates (genitals). Resident B1 immediately pulled up his pants and pushed Resident C1's hand away when he saw the nurse aide entering the room. Staff immediately separated the residents and placed Resident B1 on 1:1 supervision. Resident C1 was not able to recall the event to staff in an interview conducted moments after the incident. A review of a witness statement completed by Employee 1, a nurse aide, dated December 29, 2023, at 11:45 AM, revealed that she walked into the TV room and Resident C1 was sitting in front of a male resident {Resident B1} with her hands on is exposed private area. The employee separated both residents and notified the registered nurse (RN) and Administrator. Resident B1's inappropriate sexual behaviors towards females were known to the facility as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 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 395872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Millville, The 48 Haven Lane Millville, PA 17846 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 evidenced by the resident's care plan dated May 17, 2022. The facility failed to demonstrate the development and implementation of sufficient measures to supervise Resident B1's whereabouts and activities, including his unsupervised proximity and access to female residents to prevent sexual abuse and harrassment of female residents, including Resident C1. An interview with the Nursing Home Administrator (NHA) on January 12, 2024, at 1:30 PM, confirmed that that Resident B1 had a history of expressing sexual desires/behaviors towards female residents and staff and confirmed that the resident's care plan did not include measures to deter his unsupervised access and proximity to female residents 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 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 395872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Millville, The 48 Haven Lane Millville, PA 17846 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement an individualized plan to meet the resident's toileting needs, including timely staff assistance with toileting and incontinence management for one out of six sampled residents (Resident A1 ). Findings include: A review of facility policy titled Urinary Continence and Incontinence - Assessment and Management revealed the staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence, manage incontinence following relevant clinical guidelines, provide appropriate services and treatment to help residents restore or improve bladder function, and prevent urinary tract infections to the extent possible. Residents will be assessed for information related to urinary incontinence with staff defining each individual's level of continence, referring to the criteria in the Minimum Data Set. Nursing staff will seek and document details related to continence to include: voiding patterns, associated pain or discomfort, and types of incontinence (stress, urge, mixed, overflow, transient and functional). If the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. Staff will document the result of the toileting trail in the resident's medical record. If the resident responds well, the toileting program will be continued. If the resident does not respond and does not try to toilet, staff will use a check and change strategy. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. A review of Resident A1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), uterovaginal prolapse (muscles and tissues in the pelvis weaken and the uterus drops down into the vagina), history of urinary tract infections (UTI), and overactive bladder. A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 2, 2023, revealed that the resident was severely cognitively impaired, required extensive assistance with bed mobility, was dependent on staff for transfers and toileting, was always incontinent of urine and was not on a toileting program. A review of Resident A1's comprehensive bowel and bladder evaluation v2 dated November 2, 2023, revealed that the resident was always incontinent of urine and most likely experiencing stress incontinence (Stress incontinence occurs when your bladder leaks urine during physical activity or exertion. It may happen when you cough, lift something heavy, change positions, or exercise). The evaluation concluded that the resident was not a candidate for a toileting or retraining program. The evaluation did identify if the resident was a candidate for a prompted voiding program. A review of the Documentation Survey Report v2 for the task of Turned, Repositioned and Incontinence care provided for the month of December 2023, revealed that on: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 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 395872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Millville, The 48 Haven Lane Millville, PA 17846 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 0690 - Level of Harm - Minimal harm or potential for actual harm December 1, 2023, the resident was checked (unclear if task performed included incontinence care) at 2:44 AM, 3:34 AM, 6:24 AM, but not again until 11:57 AM. Residents Affected - Some December 2, 2023, the resident was checked at 1:34 AM, 3:27 AM, 5:30 AM and not again until 9:47 AM. December 3, 2023, the resident was checked at 2:55 AM, 3:27 AM, 5:52 AM and not again until 11:10 AM. December 6, 2023, the resident was checked at 1:21 AM, 2:37 AM, 5:30 AM not again until 9:35 AM and then not again until 2:45 PM. December 11, 2023, the resident was checked at 1:27 AM, 2:26 AM, 4:24 AM and not again until 11:27 AM. December 12, 2023, the resident was checked at 12:28 AM, 2:36 AM, 4:53 AM and not again until 11:19 AM. December 13, 2023, the resident was checked at 1:18 AM, 2:21 AM, 4:55 AM and not again until 9:50 AM. December 15, 2023, the resident was checked at 12:32 AM, 2:17 AM, 4:26 AM and not again until 10:33 AM. December 16, 2023, the resident was checked at 1:27 AM, 2:27 AM, 4:26 AM, 8:46 AM, and not again until 1:06 PM. December 19, 2023, the resident was checked at 1:26 AM, 2:26 AM, 4:36 AM, and not again until 9:53 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 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 395872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Millville, The 48 Haven Lane Millville, PA 17846 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 0690 - Level of Harm - Minimal harm or potential for actual harm December 21, 2023, the resident was checked at 1:17 AM, 3:25 AM, 4:26 AM, 8:35 AM, 10:06 AM, 1:37 PM and not again until 6:21 PM. Residents Affected - Some December 25, 2023, the resident was checked at 9:18 PM and not again until December 26, 2023, at 3:46 AM December 26, 2023, the resident was checked at 1:35 PM and not again until 7:31 PM. December 29, 2023, the resident was checked at 12:15 PM and not again until 6:00 PM. A review of the Documentation Survey Report v2 for the task of Bladder Continence for December 2023, revealed Resident A1 was incontinent 115 times out of the 125 documented episodes of bladder function for the month of December 2023. A review of the resident's plan of care in effect at the time of the survey ending January 12, 2023, revealed that the resident was identified as having mixed incontinence (Mixed incontinence, experience more than one type of urinary incontinence, a combination of stress incontinence and urge incontinence) related to dementia. There was no evidence that the facility had developed and implemented a plan to address the resident's toileting needs based on an evaluation of the resident's habits and voiding patterns and assure timely care was provided to meet the resident's toileting needs and manage the resident's urinary incontinence to prevent extended periods of time without toileting, checking for incontinence and changing the resident. A review of the resident's bladder incontinence record for the month of December 2023, revealed that staff were not checking and changing the resident every two hours. Interview with the Nursing Home Administrator on January 12, 2023, at approximately 1:00 PM confirmed that the facility was unable to provide evidence that the facility had consistently provided timely care for the resident's toileting needs, including incontinence management, the type and frequency of physical assistance necessary to assist the resident to access the toilet and the resident's potential for a prompted voiding program to decrease episodes of urinary incontinence. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 7 of 7