Health inspection·February 15, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment on four of four nursing units (Nursing Hall A, B, C and D). Findings include: An observation on February 15, 2024, at 11:47 AM in the resident TV room lounge revealed two dead bugs, approximately an inch in length, behind a red recliner. Cobwebs, dust, and debris were observed on the floor near the bugs. Multiple white stains and discolorations were observed on the arm rest and seat cushion. Dust, debris, peeling paint, and black scuff marks extending the length of the heating unit. [NAME] stains were observed on wall below the center window. An observation on February 15, 2024, at 12:08 PM in the C Hall shower room revealed small live black ants on the floor. A bathtub was observed with black pieces of debris on the base of the white tub near the drain. Hair and a rubber band were stuck in the metal strainer in the drain. Cobwebs were observed near the red floor border in the right corner of the shower room. with a buildup of dirt and food debris was visible in the corner underneath the cobwebs. An observation on February 15, 2024, at 12:11 PM in the A Hall shower room revealed multiple live black ants on a piece of food debris on the floor. Observations of the A hall and B hall nursing unit on February 15, 2024, at approximately 2:00 PM revealed the following Dirt, debris, and food particles throughout the hallways on the A hall and B hall. Observation in resident room [ROOM NUMBER] revealed a used foley catheter and urine graduate cylinder coated with a dried-urine like brown yellow substance along with a bottle of mouthwash in basin on the floor in the bathroom of the room. Dirt, debris, and food particles were observed on the floor throughout the room. Food particles were observed on the floor in A hall TV room. There was a brown substance splattered on the walls by the door. Observation in resident resident room [ROOM NUMBER] revealed dust and debris on the floor. Page 1 of 6 395872 395872 02/15/2024 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A dried brown/yellow substance was observed around the bottom of the toilet in the resident's bathroom. A brown substance was observed on the bathroom door. A dried brown substance was observed on the walls of resident room [ROOM NUMBER]. An observation on February 15, 2024, at 2:02 PM in the C Hall near the exit revealed a hole in the wall measuring approximately two inches by one inch. The hole was observed above a green floor molding. The green floor molding to the left of the C Hall exit was observed to be peeling from the wall. Rust stains and peeling paint were observed on the door frame. Several chairs in the C Hall exit corridor were observed with stained and discolored seat cushions. An observation on February 15, 2024, at 2:04 PM in resident room [ROOM NUMBER] revealed a bathroom ceiling tile with a broken corner, a black and gray scuffed bathroom door, live black ants on the floor, and multiple dead bugs in the ceiling light. The floor molding in the bathroom was stained and discolored. An observation on February 15, 2024, at 2:07 PM in resident room [ROOM NUMBER] revealed a closet door with gray scuff marks. The wall to the left of the closet door was observed to be scrapped, discolored, and chips of paint were missing, revealing white plaster and drywall. The resident's window shades were observed to have brown debris and stains. The window sill was observed to have a buildup of dirt and dust. An observation on February 15, 2024, at 2:11 PM in resident room [ROOM NUMBER] revealed bathroom dead bugs in the ceiling lights with and chipped bathroom floor tiles. An observation on February 15, 2024, at 2:15 PM outside of resident room [ROOM NUMBER] revealed brown liquid stains on the green cover of the laundry cart. During an interview on February 15, 2024, at approximately 2:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility should be maintained in a clean and sanitary manner. Refer F925 28 Pa. Code 201.18 (e)(2.1) Management 395872 Page 2 of 6 395872 02/15/2024 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's abuse policy, select investigative reports, and clinical records, and staff interview, it was determined that the facility failed to ensure four residents out of 11 sampled was free from misappropriation of resident property, medications (Resident 7, 9, 10, and 11). Residents Affected - Some Findings included: A review of the facility policy entitled Abuse Policy revealed that the residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy noted that misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residence belongings or money without the resident's consent. A review of the clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses which 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, resulting from organic disease of the brain) and anxiety disorder. The resident had a physician order dated January 24, 2024, for Ativan 0.5 mg give 0.25 mg (half tablet) by mouth every 6 hours as needed for anxiety. A review of the clinical record review revealed that Resident 9 was admitted to the facility on [DATE], with diagnoses which include dementia and anxiety. The resident had a physician order dated December 7, 2023, for Ativan (an antianxiety drug) 0.5 mg give 0.25 mg (half tablet) by mouth three times a day. A review of the clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses which include major depressive disorder. The resident had a physician order dated December 21, 2023, for Ativan 0.5 mg give 0.5 mg every four hours as needed for agitation or restlessness. A review of the clinical record review revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses which include dementia and anxiety disorder. The resident had a physician order dated February 21, 2022, for Ativan 0.5 mg give 0.25 mg (half tablet) by mouth two times a day. A review of a facility investigative report dated February 10, 2024, at 10:00 AM revealed Employee 1 LPN (licensed practical nurse) was completing medication administration pass. The employee noticed the Ativan tablet was much easier than normal to pop out of the blister pack of medications. When Employee 2 RN (registered nurse) reviewed the Ativan cards, it was found the pills were Claritin (an antihistamine), not Ativan as labeled. All medication carts were checked for similar concerns. Five cards of Ativan dispensed for Residents 7, 9, 10, and 11 were found to have the Ativan replaced with Claritin. A review of Employee 1's statement (no date or time indicated when the statement was obtained) revealed while the employee was passing medications, she went to get the Ativan for one of her residents and noticed the medication was not the right medication. The employee indicated that she brought the card to Employee 2 and upon checking the other controlled substance cards, it was found that 5 cards contained the incorrect medications. 395872 Page 3 of 6 395872 02/15/2024 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Employee 3's LPN statement (no date or time indicated when the statement was obtained), revealed that on Friday February 9, 2024, when the employee was working the A hall medication cart, she noticed the Ativan cards were easier to pop. She further stated that she spoke with Employee 1 about this concern and indicated Employee 1 felt the same way and she made the nursing supervisor aware. An interview with Employee 1 on February 15, 2024, at approximately 11:30 AM revealed while she was preparing Resident 9's medications, the Ativan tablet looked different. The employee indicated that the pill was easy to pop out of the medication card. The employee stated she took the card right to Employee 2 and let her know that someone switched out the resident's medication. Employee 1 stated that she was off on February 7, 8, and 9, 2024, but she did provide the medication to Resident 9 on February 6, 2024, and she knew the pills were the right pills on February 6, 2024. Further Employee 1 stated she was the one who had received Resident 19's Ativan card delivered from the pharmacy and the card was correct with the correct pills in it when it was received at the facility. An interview with Employee 3 on February 15, 2024, at 11:36 AM revealed the employee stated on February 9, 2024, she worked on the A hall medication cart. At that time, she noticed the Ativan pills were easier to pop out of the cards. When alerted on February 10, 2024, by Employee 1 that the pills in the Ativan cards appeared different, Employee 3 voiced her concerns that the Ativan was easy to pop, and they notified Employee 2. An interview with Employee 2 on February 15, 2024, at 11:47 AM revealed the employee stated it was brought to her attention by Employee 1 that Resident 1's Ativan card had been tampered with and the pills in the card were not Ativan. Employee 2 stated they started an investigation and determined that Resident 7, 9, 10, and 11's Ativan pills had all been swapped out with Claritin. The employee stated the misappropriated medications were only identified in the A hall medication cart. An interview with the NHA on February 15, 2024, at approximately 2:30 PM confirmed the facility failed to ensure all residents were free from misappropriation of resident property, their medications. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights 395872 Page 4 of 6 395872 02/15/2024 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of facility provided documents, and resident and staff interviews, it was determined that the facility failed to maintain an effective pest control program, including observations made on two of the four nursing units (Nursing Halls A and C). Residents Affected - Some Findings include: A review of the facility's Pest Sighting Log revealed an entry dated November 27, 2023, indicating that live ants were observed in resident room [ROOM NUMBER]. The number of ants was listed as a lot. A pest sighting entry dated December 10, 2023, indicated that residents reported killing three brown bugs in resident room [ROOM NUMBER]. A pest sighting entry dated December 14, 2023, indicated that black bugs were observed in the bathroom in resident room [ROOM NUMBER]. A review of the facility's pest control service inspection report dated December 15, 2023 revealed two services were provided, drain service and pest management. The service inspection report indicated that no conditions were added for this service and no conditions were resolved for this visit. The report indicated that eight rodent bait stations were inspected and maintained. The report failed to indicate any services that targeted bugs or rooms identified with pests that were reported by residents or staff and noted in the facility's pest sighting logbook. A pest sighting entry dated December 16, 2023, indicated that ants were in the hallway coming from the SS {social service} office. A pest sighting entry dated December 25, 2023, indicated that ants were in resident room [ROOM NUMBER]. The number of ants was indicated as many. A review of the facility's pest control service inspection report dated January 22, 2024, revealed two services were provided, drain service and pest management. The service inspection report indicated that no conditions were added or updated for this service, and no conditions were resolved for this visit. The report indicated that seven rodent bait stations were inspected and maintained. The report failed to indicate any services that targeted bugs or rooms identified with pests that were reported by residents or staff and noted in the facility's pest sighting logbook. A pest sighting entry dated January 28, 2024, indicated that were observed ants in resident room [ROOM NUMBER]. The number of ants was indicated as a lot. An observation on February 15, 2024, at 11:47 AM in the resident TV room lounge revealed two dead bugs approximately an inch in length behind a red recliner. An observation on February 15, 2024, at 11:50 AM in the kitchen revealed multiple dead bugs in the ceiling light fixtures. A clinical record review revealed Resident 5 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process 395872 Page 5 of 6 395872 02/15/2024 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some conducted periodically to plan resident care) dated February 7, 2024 revealed that Resident 5 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During an interview on February 15, 2024, at 12:00 PM, Resident 5 stated that she had her room was changed because there were ants all over the room. She described the pests as small black ants and stated that some had wings. Resident 5 explained that one day the ants were all over the floor, her bed, and crawling on her body, which upset her. An observation on February 15, 2024, at 12:08 PM in the C Hall shower room revealed small live black ants on the floor. An observation on February 15, 2024, at 12:11 PM in the A Hall shower room revealed multiple live black ants on a piece of food debris on the floor. An observation on February 15, 2024, at 2:04 PM in resident room [ROOM NUMBER] revealed live black ants on the bathroom floor, and multiple dead bugs in the ceiling light. An observation on February 15, 2024, at 2:11 PM in resident room [ROOM NUMBER] revealed multiple dead bugs in the bathroom ceiling light. During an interview on February 15, 2024, at approximately 2:30 PM, the Nursing Home Administrator and Director of Nursing failed to provide evidence of effective functioning pest control program. 28 Pa. Code 201.18 (e)(2.1) Management 395872 Page 6 of 6