Health inspection·April 12, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some like substance, hair and debris were observed on the base of the toilet, along with a sticky brown film surrounding the base of the toilet. There was a brown film surrounding the water controls in the sink. An observation on April 10, 2024, at 10:05 AM in resident room [ROOM NUMBER] revealed an overbed table with sticky film on top. The table legs and wheels had a buildup of sticky brown film. The base boards running the perimeter of the floor were dirty and observed to have a sticky brown film. A thick yellow urine like substance, hair and debris were observed on the base of the toilet and a sticky brown film was also observed surrounding the base of the toilet. During an interview on April 11, 2024, at approximately 12:30 PM, the Nursing Home Administrator (NHA) confirmed that the facility is be maintained in a clean and sanitary manner. 28 Pa. Code 201.18 (e)(1)(2.1) Management 28 Pa. Code 201.29 (a) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 2 of 29 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 04/12/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select facility policies and staff interviews, it was determined that the facility failed to thoroughly investigate injuries of unknown origin, bruising, to rule out abuse, neglect or mistreatment as the potential cause for one out of 20 sampled residents (Resident 90). Residents Affected - Few Findings included: A review of the facility's policy Abuse Policy that was last reviewed by the facility on June 21, 2023, indicated that a timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown sources, misappropriation of resident property) and reasonable suspicion of a crime resulting in bodily injury will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) if the alleged does not involve abuse AND has not resulted in serious bodily injury. The facility policy entitled Accidents and Incidents - Investigating and Reporting that was last reviewed by the facility on June 21, 2023, indicated that the Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data shall be included on the Report of Incident/Accident form: the nature of the injury/illness (e.g., bruise); circumstances surrounding the incident; where the accident took place; the name(s) of the witnesses and their accounts of the accident or incident; the time the injured person's Attending Physician was notified, as well as the time the physician responded and his/her instructions; the date and time the injured person's family was notified; the condition of the injured person, including his/her vital signs; any corrective action taken; follow-up information; other pertinent data as necessary or required. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing within 24-hours of the incident or accident. A review of Resident 90's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), history of falls, and generalized muscle weakness. Progress notes completed by Employee 7, a licensed practical nurse (LPN), dated January 22, 2024, at 5:43 p.m., indicated that this nurse {Employee 7} found bruises on the resident as follows: one on the left hip measuring 17.0 centimeters (cm) by 5.5 cm deep and purple in color, one on the left inner thigh 7.0 cm by 4.0 cm deep purple in color, and one on inner left wrist measuring 1.0 cm by 0.5 cm and was purple in color, and one on left wrist distal from first one 0.9 cm by 2.5 cm. Resident had no recollection on how the bruises formed. The bruises were measured, and RN was made aware. Alarms were placed on resident bed. MD made aware and resident representative (RP) called At the time of the survey ending April 12, 2024, there was no documented evidence that the facility had investigated the potential origin of Resident 90's bruises to rule out abuse, neglect or mistreatment as the potential cause of the injuries. During an interview with the Director of Nursing (DON) on April 11, 2024, at 11:25 a.m., revealed that she was unaware of Resident 90's bruises that were identified by Employee 7. The DON confirmed that the facility failed to implement the facility's abuse prevention policy related to investigating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 3 of 29 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 04/12/2024 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 0610 the bruising of unknown origin that were found on Resident 90 by Employee 7. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29(a)(c)(d) Resident rights 28 Pa. Code 201.14(a) Responsibility of Licensee Residents Affected - Few 28 Pa. Code 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 4 of 29 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 04/12/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one resident out 20 sampled (Resident 299). Findings include: Review of Resident 299's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include ischemic cardiomyopathy (the hearts decreased ability to pump blood properly due to heart damage), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow), and the presence of an automatic implantable cardiac defibrillator (AICD- is a microcomputer that is implanted under the skin of the upper chest area. It monitors heart rate and delivers therapy in the form of small electrical pulses. An AICD is a permanent device inserted into the right ventricle and typically placed near the collarbone under the skin of the chest). There was no documented evidence at the time of the survey ending April 12, 2024, that the facility timely identified and addressed the resident's care needs related to the AICD device as an area of focus with interventions to provide AICD checks as ordered or to monitor for signs and symptoms of AICD complications. The facility failed to address the emergency care of the AICD device and actions to be taken if the AICD was activated (i.e., consulting the physician, obtaining vital signs [clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] and keeping the resident and staff safe from the electrical shock. The resident should notify staff if a shock is felt, and staff should be aware not to touch resident is being shocked since the shock can be felt) Interview with the Nursing Home Administrator and Director of Nursing on April 12, 2024, at 9:00 AM confirmed that the facility failed to sufficiently address the care and management of Resident 299's AICD on the resident's baseline plan of care. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 5 of 29 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 04/12/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services planned to maintain the mobility and functional abilities of one of the 20 residents sampled (Resident 16). Findings included: A clinical record review revealed that Resident 16 was admitted to the facility on [DATE], with diagnoses that included end-stage renal disease (final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 28, 2024, revealed that Resident 16 is cognitively intact with a BIMS score of 15 (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). Resident 16's care plan, initiated July 29, 2019, revealed that the resident had the potential for a decline in ambulatory function and the need for a restorative program. Planned interventions were for the resident for the resident to receive 50 feet of restorative walking with a two-wheeled walker and the assistance of one staff member. A Physical Therapy Discharge summary dated [DATE], revealed that Resident 16 reached her maximum potential with skilled therapy services. The discharge recommendation was for the facility to establish a restorative ambulation program to include the resident ambulating 50 feet daily with a two wheeled walker (mobility device) and with the assistance of one staff member. The summary noted that Resident 16 had a good prognosis to maintain her current level of functioning with consistent staff follow-through. Facility tracking of staff completion of the task of providing the resident's restorative walking dated from March 19, 2024, through April 10, 2024, revealed that Resident 16 refused to be assisted with walking 16 times, participated in the walking five times, and the task was not applicable once. During an interview on April 9, 2024, at 10:26 AM, Resident 16 stated that staff are not providing her a restorative ambulation program. She stated that the facility staff did not offer or provide her the restorative walking assistance for her walk 50 feet with a two-wheeled walker. The resident stated that she would like to get stronger and walk more often. Further review of the facility's tracking of the task of restorative walking task, revealed that on April 9, 2024, at 12:36 PM, Resident 16 declined to attend the restorative nursing program for walking, on April 10, 2024, at 11:44 AM nursing noted that Resident 16 was not available for the program, Resident 16 had a dialysis appointment on April 10, 2024, however, the Resident 16 returned to the facility on 12:38 PM on April 10, 2024. During an interview on April 11, 2024, at 9:45 AM, Resident 16 stated nursing staff did not offer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 6 of 29 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 04/12/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some or provide her restorative nursing program for walking intervention 50 feet with a two-wheeled walker on April 9th or April 10th, 2024, nor did the resident refuse to ambulate on those dates as noted in the task documentation. During an interview on April 11, 2024, at approximately 13:30 PM, the Nursing Home Administrator (NHA) confirmed that Resident 16 is alert and oriented and aware of her care and should be provided the restorative nursing services planned. The NHA was unable to state why staff were not consistently providing the program and documenting the resident's refusals, when the resident stated that the program was not offered on those dates. 28 Pa. Code: 211.5(f) Medical records 28 Pa. Code: 211.12(c)(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 7 of 29 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 04/12/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 a review of clinical records and water temperature logs, observations, and resident and staff interviews it was determined that the facility failed to maintain an environment free of potential accident hazards by failing to maintain hot water temperatures within a safe range for residents, including Resident 12, 13, and 69, residing on the [NAME] Hall A and B unit, placing these 27 residents out of 97 residents residing in the facility in immediate jeopardy due to the potential for serious burns. Findings include: According to the U.S. Consumer Product Safety Commission, most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 F degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 F degrees, a five-minute exposure could result in third-degree burns. Observation on the A unit, April 10, 2024, at 9:04 AM revealed that the temperature of the hot water in the bathroom sink of resident room [ROOM NUMBER] was 115.6 Farenheit. Observation on the A unit, April 10, 2024, at 9:13 AM revealed that the hot water temperature in the facility's [NAME] Wing shower room measured 121.5 Farenheit. Observation on the A unit, April 10, 2024, at 9:24 AM revealed that the hot water temperature at the sink in the bathroom in resident room [ROOM NUMBER] was 119.9 Farenheit. During an interview on April 10, 2024, at 9:29 AM, Employee 3, a nurse aide, stated that she took the morning water temperatures earlier this morning, prior to showering residents. She explained that the facility never trained her on the procedure for checking water temperatures prior to showering residents, but she figured out the method on her own. She explained that there is a blue thermometer in the shower stall to measure the water temperature. When asked to demonstrate how she measures and records the water temperature obtained prior to showering residents, Employee 3, nurse aide, was observed looking at the blue thermometer but not placing the thermometer under the flowing water. She stated that the thermometer read 80 degrees Farenheit. She explained that she always makes sure the water is safe by testing it with her hand and asking residents if the water is comfortable. She stated, at the time of this interview, she had just completed Resident 13's shower. During an interview on April 10, 2024, at 9:33 AM, Employee 4, nurse aide, stated that he was trained to utilize a blue thermometer that was hanging in the shower. He stated that the water shower temperature is then recorded on the temperature log sheet. He stated that he was not aware of a temperature that was too high for the residents to be showered. He explained that he always asks the residents about their comfort with the water temperature and feels the water temperature prior to letting residents shower. During an observation on April 10, 2024, at the same time as the interview, the facility's [NAME] Wing shower room water temperature measured 128 Fahrenheit. The measurement was taken by Employee 4, nurse aide. During a resident group interview on April 10, 2024, at 10:00 AM, Resident 69 stated that when he independently takes showers, the water temperatures fluctuate from hot to cold. He explained that when the water becomes too hot, he points the shower handle away from his body. Resident 69 stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 8 of 29 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 04/12/2024 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 0689 he may have to wait up to two minutes before the water temperature is comfortable enough to resume showering with the water. Level of Harm - Immediate jeopardy to resident health or safety Water temperatures were obtained in the bathrooms of the resident rooms the B unit (locked dementia unit) and common bathing/shower room on April 10, 2024, at approximately 10:30 AM: Residents Affected - Some Resident rooms 216 & 217 -122.2 degrees Fahrenheit Resident room [ROOM NUMBER] (a four bedded room) 122.7 degrees Fahrenheit Resident room [ROOM NUMBER]/221- 133.8 degrees Fahrenheit Resident room [ROOM NUMBER]/225--128.8 degrees Fahrenheit Resident room [ROOM NUMBER]/226--129.7 degrees Fahrenheit Resident room [ROOM NUMBER] & 222--119.9 degrees Fahrenheit Resident room [ROOM NUMBER] & 211-- 134.6 degrees Fahrenheit Resident room [ROOM NUMBER] (a single room) - 127 degrees F, the cold water in the sink did not work at the time of the observation. Observation in Resident room [ROOM NUMBER] at this time, revealed Resident 12, who was alert and oriented was attempting to use the sink in her room to wash her hands. The resident confirmed that the cold water did not work but she was ok to use just the hot water. The surveyor redirected the resident another area to wash her hands with a safe water temperature at that time or perform hand hygiene. The B unit resident shower hot water temperature was 124.4 degrees Fahrenheit. There were 27 residents residing on the B unit locked dementia unit, all who utilized the shower on the unit for bathing and some utilized the sinks in their respective resident rooms. An observation April 10. 2024 at 9 AM in the resident common shower area on the west hall B unit revealed a clipboard with water shower temperature listings dated March 23, 2024 through April 5 , 2024. The documentation noted that all that all the water shower temperatures were noted to be exactly 100 degrees Fahrenheit. During an interview on April 10, 2024 at 9 AM Employee 1, a nurse aide, stated that she was routinely scheduled to work in the B unit (locked dementia unit). She stated that the hot water temperature at the sinks in the resident rooms on the unit has been really hot for a while. She stated that the unit shower water was also really hot. Employee 1 stated that the Director of Nursing (DON) told her to document 100 degrees Fahrenheit for every shower given despite the actual temperature obtained. During an interview on April 10, 2024 at 9:05 AM, Employee 2, a nurse aide, stated that hot water in the resident room sinks and the common resident shower is very hot. She stated that the DON instructed her, after taking a shower water temperature, to document (on the designated shower temperature (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 9 of 29 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 04/12/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some log, located in the shower room) 100 degrees Fahrenheit no matter what the actual temperature reads on the thermometer. An interview with the Nursing Home Administrator at 1:30 PM on April 10, 2024, revealed that the NHA confirmed that the elevated hot water temperatures obtained and noted above were correct. He also verified that Resident 12 was at risk for burns due to the temperature of the hot water at the sink in the resident's room and the lack of running cold water at the sink at the time of the observation. He further stated that an unknown employee turned the cold water off underneath the sink in Resident 12's room, failed to tell maintenance of any issues, and did not turn the cold water back on for resident use. The NHA was unable to state how long the hot water temperatures were at an unsafe level. Immediate Jeopardy was called on April 10, 2024, due to the facility's failure to ensure that the environment for the residents on the [NAME] unit, the A and B (locked dementia unit) resident hallways was free of potential accident hazards in the form of elevated hot water temperatures. The facility was notified of the Immediate Jeopardy on April 10, 2024, at 11:15 AM and the IJ template provided to the facility. An immediate plan of correction was requested and received on April 10, 2024. The plan included: -The plumber was called at 11:30 AM, April 10, 2024 and arrived shortly there after to diagnosis the problem. -The hot water to the west side of the facility was temporarily turned off at 11:15 AM. Hot water will be rerouted from a second hot water heater (servicing the East side of the facility) by April 10, 2024 at 3:30 PM. -The cold water tap in resident room [ROOM NUMBER] will be repaired by April 10, 2024 at 3 PM. -All staff will be reeducated on the proper method of assessing water water temperatures prior to washing bathing and showering residents to assure accuracy of the temperature to timely assure accuracy of hot water temperatures. Education will be complete April 10, 2024. -Random water temperatures throughout the facility will be checked every shift on each hall to avoid future occurrences starting April 10, 2024. - During the time period the hot water is off, hand sanitizer and hot water from unaffected areas in the building will be used to meet resident needs. The Immediate Jeopardy was lifted on April 10, 2024, at 5 PM when the removal plan was verified as completed. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.12 (c)(d)(5) Nursing services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 10 of 29 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 04/12/2024 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 0689 28 Pa. Code 205.37 (c) Equipment for bathrooms Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 11 of 29 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 04/12/2024 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 clinical records and select facility policy and staff interviews, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia-related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for one resident out of 20 sampled (Resident 14). Residents Affected - Few Findings include: A review of facility policy titled Alzheimer/Dementia Disease, last reviewed by the facility on June 21, 2023, indicated that Dementia care requires constant adjustments. New challenges arise, meaning that a caregiver must be constantly observant to behavioral changes. A clinical record review revealed Resident 14 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and unspecified psychosis (a disturbance in thought and perception disrupting a person's ability to discern reality). An annual comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 26, 2024 revealed that Resident 14 is moderately cognitively impaired with a BIMS score of 09 (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 8-12 moderate cognitive impairment). Resident 14's care plan, initiated April 11, 2014, indicated that the resident uses psychotropic medications for psychosis with behaviors like yelling at others and false beliefs or repetitive verbalizations of not wanting to go to the hospital. Planned interventions included asking the resident to show her stuffed animal collection, asking the resident what she needs, offering the resident soda, a nap, coloring, and reorientation. The most recent intervention added, June 5, 2023, was that if the resident is exhibiting aggression, attempt a second caregiver; if this continues to be ineffective, staff is to ensure the resident is in a safe position, and re-approach at a later time. The resident's care plan, initiated August 6, 2012, also indicated that the resident has a chronic and progressive decline in intellectual functioning characterized by a deficit in memory, judgment, decision-making, and thought processes related to Alzheimer's disease with interventions of allowing adequate time for resident response, attempting a second caregiver when the resident is upset, and attempting to de-escalate the resident. A review of the resident's care plan, and progress notes in the clinical record dated during the months of September 2023, November 2023, and April 2024, that the resident displayed physical and aggressive behaviors towards others. The resident's care plan for physical aggression, however, had not been revised since June 5, 2023, despite the resident's ongoing display of these behaviors, there was no review of the existing currently planned interventions in reducing or managing these behaviors. A progress note dated November 2, 2023, at 10:36 AM revealed that Resident 14 became aggressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 12 of 29 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 04/12/2024 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 0744 Level of Harm - Minimal harm or potential for actual harm towards a nurse aide when attempting to assist the resident with a transfer and that redirection was effective. A progress note dated November 9, 2023, at 2:30 PM revealed that Resident 14 kicked and attempted to punch and pinch nurse aides; staff explained to the resident why this behavior was unacceptable. Residents Affected - Few A progress note dated November 17, 2023, at 2:30 PM revealed that Resident 14 yelled and hit the housekeeper who was cleaning the floor in the resident's room, and redirection and offering coffee were ineffective. The resident's treatment report record dated February 2024 revealed Resident 14 presented with agitation, paranoia, physical aggression, and/or verbal aggression on February 18, 19, 20, 21, and 22 of 2024. Interventions attempted on February 18, 2024, but were ineffective and the interventions were not applicable on February 19, 20, 21, and 22. There was no additional documentation describing the resident's behavior or the interventions attempted. A progress note dated March 6, 2024, at 1:54 AM indicated that social services met with Resident 46 to provide education regarding her recent incident of yelling at another resident. The resident's treatment report dated March 2024 revealed that the resident presented with agitation, paranoia, physical aggression, and/or verbal aggression on March 12, 2024, and no interventions were implemented, and the result was effective. A clinical record review failed to reveal further information describing the resident's behavior. A progress note dated April 3, 2024, at 6:04 PM indicated that Resident 14 became physically aggressive with staff and punched a nurse and staff provided education to the resident. Interview on April 11, 2024, at approximately 2:30 PM, with the NHA, failed to provide evidence that facility evaluated the interventions planned, and implemented, through an interdisciplinary team approach, to meet the resident's dementia care needs and in response to the resident's dementia related behavioral symptoms for their continued appropriateness and effectiveness in managing, modifying or limiting the resident's dementia related behavioral symptoms. 28 Pa. Code 201.18 (e)(1) Management 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 13 of 29 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 04/12/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of controlled drug records and staff interview, it was determined that the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for one of 20 residents sampled (Resident 36) . Finding include: A review of the clinical record revealed that Resident 36 had a physician order dated January 18, 2024, for Oxycodone (a narcotic opioid pain medication) 10 mg Tablet, one tablet every 6 hours as needed for severe pain 7-10 (a pain scale, 1-10, 1 least pain, 10 most pain). A review of the controlled substance record accounting for the above narcotic medication revealed that on April 1, 2024, at 12:00 AM, April 1, 2024 at 11:45 AM, April 2, 2024, at 8:30 PM, April 4, 2024 at 11:40 PM, April 5, 2024 at 5:30 PM, April 6, 2024, at 5:30 AM, April 7, 2024, at 5:37 AM, April 8, 2024, at 11:30 AM, and April 8, 2024, at 12:30 PM, nursing staff signed out a dose of the resident's supply of Oxycodone 10 mg . However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times. A review of Resident 36's MAR for December 2023, revealed nursing signed out 106 doses of the resident's supply of Oxycodone 10 mg. January 2024, MAR revealed 97 doses of Oxycodone 10 mg was signed out. February 2024, MAR revealed 88 doses of Oxycodone 10 mg was signed out. March 2024 from March 1-March 28, 2024, revealed 96 doses of Oxycodone was signed out. There was no controlled drug narcotic sign out records available at the time of the survey ending April 12, 2024, for the months of December 2023, January 2024, February 2024, and March 1-28, 2024, to reconcile the accounting of the resident's supply of the controlled drug. During an interview, April 11, 2024, at 1:25 PM the Director of Nursing confirmed the inconsistencies in the accounting and administration of the opioid pain medications for the above resident and confirmed the narcotic drug records were missing for the above months and not available to reconcile with the quantity dispensed for the resident and to verify administration to the resident on those date and times. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa Code 211.9(a)(1)(2)(k) Pharmacy services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 14 of 29 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 04/12/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 clinical records and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 20 residents sampled (Resident 15). Residents Affected - Few Findings included: Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include dementia, chronic kidney disease stage 3 and was severely, cognitively impaired. A review of an RN Practitioner assessment of the resident dated March 15, 2024, revealed that a Chart review indicates {Resident 15} with multiple UTIs in the past, asked nursing to collect urine and dip is suspicious for UTI sent for U/A C&S (urinalysis and culture and sensitivity), initial urine appears suspicious for infection, collect U/A C&S via straight cath. The noted plan included Elevated white blood cell count, no clinical signs of infection, vital signs stable, collect U/A C&S (urinalysis and culture and sensitivity). The RN practitioner ordered a urinalysis and culture and sensitivity (report to indicate what antibiotic will treat the infection) to rule out a urinary tract infection at that time and ordered Augmentin (an oral antibiotic medication) 500/125 mg, one by mouth twice a day for 5 days for UTI (urinary tract infection) on March 15, 2024. Nursing documentation dated from March 1, 2024, through March 15, revealed no documentation that the resident was displaying signs or symptoms of a UTI. A review a nurses note dated March 19, 2024, at 1:31 PM revealed that a new order was noted from the CRNP to discontinue Augmentin, and start Ceftin 250 mg BID x 5 days. An RN Practitioner assessment dated [DATE], revealed Examined bedside follow-up, reviewed U/A C&S, mother suspicious of UTI will start Ceftin 250 mg twice daily and encourage fluids. The CRNP order dated March 19, 2024, was noted for Ceftin 250 (an oral antibiotic) mg twice daily, for 5 days for UTI. A review of the resident's March 2024 medication administration record (MAR) revealed that Resident 15 received Augmentin 500/125 mg by mouth on March 17th, two doses, March 18th two doses and one dose on March 19th. According to the March 2024 MAR, Augmentin was discontinued on March 19, 2024, and Ceftin 250 mg, by mouth, twice daily was given as prescribed until March 24, 2024 (10 doses). A review of a culture and sensitivity results dated March 21, 2024, revealed that Resident 15's urine contained greater than 100, 000 colonies/ml Klebsiella pneumonae bacteria. The corresponding sensitivity report did not include the initial antibiotic prescribed for the resident, ( Augmentin ). There was no corresponding prescriber documentation to indicate the rationale for initiating Augmentin, prior to receipt of the results of the C & S, and then discontinuing Augmentin after five doses, then starting Ceftin, prior to receiving the results of the C & S. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 15 of 29 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 04/12/2024 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 0757 Interview with the Director of Nursing on April 12, 2024, at 12:45 PM, confirmed that the administration of Augmentin was not clinically justified for treatment of Resident 15's UTI Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.2 (3) Medical Director Residents Affected - Few 28 Pa. Code 211.9 (k) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(3) Nursing Services 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 16 of 29 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 04/12/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, a review of select facility policy and staff interview, it was determined that the facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications on one of two medication storage rooms (Med Room West). Findings include: A review of the facility policy titled Vials and Ampules of Injectable Medications, last reviewed by the facility June 21, 2023, indicate that the purpose is to ensure medications are used in accordance with the manufacturer's recommendations or the provider pharmacy directions for storage, use, and disposal. The beyond use date and initials of the first person to use the vial are recorded on the multidose vials. Medication in multidose vials may be used for twenty-eight days if inspection reveals no problems during that time. An observation of the medication room on the [NAME] Wing on April 10, 2024, at 9:05 AM, in the presence of Employee 6 (RN Supervisor), of medication stored in the medication refrigerator revealed a multi-dose bottle of Aplisol (solution used for screening for tuberculosis) that had been opened and dated November 19, 2023. Review of the manufacturer dosage and administration for Aplisol revealed that vials in use for more than 30 days should be discarded. The current vial was 5 months beyond the manufacturer's recommended discard date. Further observation of the refrigerator revealed a multi-dose vial of Spikevax (COVID 19 vaccine) opened and dated with a discard date of March 20, 2024, 21 days beyond the discard date. The above observations were confirmed by Employee 6. Interview with the Nursing Home Administrator and Director of Nursing on April 12, 2024, at approximately 9:05 AM confirmed that medication expiration/use by dates were to be checked prior to administration and removed from the medication refrigerator upon expiration. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 17 of 29 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 04/12/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, a review of facility's planned menus and resident and staff interview it was determined that the facility failed to serve menus that accommodated, to the extent possible, the food preferences of the resident population, to promote acceptance and satisfaction with meals, including three residents of 20 residents reviewed (Resident 69, 80, and 91). Findings included: During an interview with Resident 69 on April 9, 2024, at 1:00 p.m., the resident stated that that the food served lacks flavor and the facility menu lacks variety. He reported that he regularly attends food committee meetings and voices his concerns regarding the lack of a varied menu, such as repetitive menu options. Resident 69 stated that the Certified Dietary Manager (CDM) was very understanding and did a good job, but he feels that her hands are tied due to budgetary restraints from the facility's corporate staff. Resident 69 stated that the facility's CDM and Registered Dietitian (RD) weren't involved in the development of the menu and that the corporate dietitian develops the menu for multiple long-term care facilities owned by the facility's corporation without considering the resident population in each facility's location, including local and cultural preferences of the residents in each building. During a group meeting with residents conducted on April 10, 2024, at 10:00 a.m., residents in attendance reported that the facility's menu was very repetitive and that they receive the same types of meals multiple times per week, and even for consecutive meals in a row. Resident 80 stated that he was frustrated that the facility does not listen to residents' suggestions about food. Resident 80 stated that the new Spring/Summer menu includes several of the same meals as the Fall/Winter menu. Resident 80 reported that the menu had offered grilled cheese, but the facility doesn't have a grill to properly cook the sandwich and questioned why would they {the facility's corporate dietitian} put it on the menu if they don't have the equipment to make the food here? Resident 91 stated that the menu included too much beef and chicken served. A review of the facility's regular 4-week menu cycle Spring/Summer Menu: Week 1 Regular Diet, revealed the following meal patterns: Sunday lunch the planned meal was meatloaf (ground beef) and at dinner a hot turkey (poultry) sandwich and then on Monday at lunch chicken tenders (poultry) and Monday dinner hamburger on a bun (ground beef). At the Wednesday dinner, the planned meal was grilled cheese, however the facility had to substitute this meal due to not having the equipment in the kitchen to prepare for the census. Wednesday dinner was spaghetti and meatballs and lunch on Thursday was Salisbury steak (beef two meals in a row). A review of Spring/Summer Menu: Week 2 Regular Diet, revealed the following meal patterns: Monday dinner was chicken Monterey and Tuesday dinner was herbed turkey; on Wednesday lunch entree (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 18 of 29 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 04/12/2024 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 0806 was chicken parmesan and a turkey sandwich was served Thursday dinner. Level of Harm - Minimal harm or potential for actual harm Week 2 Saturday lunch was meatloaf and then on for Sunday week 3 dinner a meatball hoagie (ground beef). Residents Affected - Some A review of Spring/Summer Menu: Week 3 Regular Diet, revealed the following meal patterns: Sunday week 3 lunch orange glazed turkey, and Monday week 3 lunch was BBQ chicken, and for Tuesday dinner a chicken salad sandwich (repeat chicken entree). Tuesday lunch was hamburger on a bun and then on Wednesday dinner was lasagna and meat sauce (repeat ground beef) Thursday week 3 dinner was baked macaroni and cheese with stewed tomatoes; Lunch on Friday was cheese pizza (repeat cheese and tomato combination) A review of Spring/Summer Menu: Week 4 Regular Diet, revealed the following meal patterns: Monday week 4 lunch was chicken and biscuits, and Tuesday dinner was a turkey sandwich. Monday Week 4 dinner was beef chili and Tuesday lunch was spaghetti and meatballs (repeat ground beef). Thursday week 4 lunch was ranch chicken and Saturday lunch was chicken parmesan with penne. Friday week 4 lunch was baked macaroni and cheese with stewed tomatoes and for Friday dinner a cheese pizza (same menu as the prior Friday). During an observation of the lunch meal on April 9, 2024, at 12:00 p.m., revealed that the planned dessert for lunch was watermelon. However, mixed fruit cocktail was substituted for watermelon. During an interview with the CDM on April 9, 2024, at 1:00 p.m., the CDM stated that mixed fruit was substituted due to the cost of watermelon. She stated that the cost of watermelon was $15.00 per melon due to the fruit not being in season and exceeding the facility's food budget. During an interview with the facility's CDM on April 11, 2024, at 12:45 p.m., the CDM confirmed that the facility's kitchen does not have a grill cooktop to accommodate making a large quantity of grilled cheese sandwiches. The CDM confirmed that the corporate RD creating the menu did not consider the equipment available at the facility or the local culture and preferences of the facility's residents when planning menus. Interview with the Nursing Home Administrator (NHA) on April 12, 2024, at 10:00 AM, confirmed that the facility failed to develop menus that reflect variety and accommodated resident preferences 28 Pa. Code 211.6 (a) Dietary services 28 Pa. Code 201.18 (a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 19 of 29 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 04/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department, and Alzheimer's dementia care unit kitchenette/pantry area, and East and [NAME] medication rooms. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of a facility policies entitled Storage Areas and Handling Clean Equipment and Utensils last reviewed by the facility on June 21, 2023, indicated that food storage facilities should keep food safe, wholesome, and appetizing and stored in an area that is clean, dry, and free from contaminants. All containers must me legibly and accurately labeled and dated. Food is stored at a minimum of six-inches above the floor and eighteen-inches from the ceiling and on clean racks or other clean surfaces that are protected from splash, overhead pipes, or other contamination (i.e., sprinklers, sewer/waste disposal pipes, and vents). All foods will be stored off the floor. Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from contamination by splashes and dust. Other stored utensils should be covered or inverted whenever possible. The initial tour of the kitchen was conducted with the facility's Certified Dietary Manager (CDM) on April 9, 2024, at 9:15 a.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified: Upon entering the walk-in produce/milk 19 cases of food was observed stored directly on the floor. Four cases of thawed four-ounce high calorie shake supplements, were not dated with a thaw date/discard date. The manufacturer's label noted that nutritional shakes and drinks were to be used within 14 days of thawing. Interview with the CDM at that time confirmed that the cases of four-ounce shakes were thawed and lacked dates and the CDM was not sure when the shakes were thawed for use. Observation inside of the dry storage area that there were two plastic bins that contained bulk flour and sugar that were not dated when filled. There were two ceiling tiles, near the wall air conditioning unit, that had brown colored stains. Observation of the dry storage areas revealed serving food serving utensils and food preparation utensils, uncovered, and hanging on the wall, next to utility pipes and under water stained ceiling tiles. During a tour of the dementia care unit's kitchenette on April 9, 2024, at 11:18 a.m., revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 20 of 29 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 04/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many that inside of the resident freezer there was a gallon of vanilla ice cream dated December 2023 that was melted and refrozen and had ice crystals covering the surface of the food. Also, there were six frozen cheese pizzas that were not dated. A sticky brown substance was observed splattered on the cabinets and wall above the stove hood and on the ceiling. An accumulation of dirt and debris with sticky splatter was observed on the floor in the dementia care unit kitchenette A dirty broom and dust pan were left on the side next to the wall ovens. An observation of the East Wing medication room and in the presence of Employee 6, RN Supervisor, on April 10, 2024, at 8:55 a.m., revealed a 32-ounce fortified nutritional shake opened and not dated when opened. The manufacturer's label indicated that the shakes should be consumed/used within four days after opening. Employee 6 confirmed the that the shake was not dated and the open date was unknown. Observation of the [NAME] Wing medication room on April 10, 2024, at 9:10 a.m., revealed that there was one 4-ounce high calorie shakes dated March 26, 2024, beyond the manufacturer's recommended 14-day discard date. One 4-ounce high calorie shake also lacked a thaw date or discard date. During an interview with the Nursing Home Administrator (NHA) on April 10, 2024, at 1:30 p.m., confirmed that the facility failed to ensure that the dietary department and resident pantry/kitchenette food storage were maintained in a sanitary manner and failed to ensure proper labeling 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 21 of 29 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 04/12/2024 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and a review of clinical records and water temperature logs it was determined that the facility was not administered in a manner to effectively use its resources to promote safety and physical well-being of residents by failing to ensure safe hot water temperatures on the [NAME] Hall A and B unit. Residents Affected - Some Findings included: A review of clinical records and water temperature logs, observations, and resident and staff interviews it was determined that the facility failed to maintain an environment free of potential accident hazards by failing to maintain hot water temperatures within a safe range for residents, including Resident 12, 13, and 69, residing on the [NAME] Hall A and B unit, placing these 27 residents out of 97 residents residing in the facility in immediate jeopardy due to the potential for serious burns. According to the U.S. Consumer Product Safety Commission, most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 F degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 F degrees, a five-minute exposure could result in third-degree burns. Observation on the A unit, April 10, 2024, at 9:04 AM revealed that the temperature of the hot water in the bathroom sink of resident room [ROOM NUMBER] was 115.6 Farenheit. Observation on the A unit, April 10, 2024, at 9:13 AM revealed that the hot water temperature in the facility's [NAME] Wing shower room measured 121.5 Farenheit. Observation on the A unit, April 10, 2024, at 9:24 AM revealed that the hot water temperature at the sink in the bathroom in resident room [ROOM NUMBER] was 119.9 Farenheit. During an interview on April 10, 2024, at 9:29 AM, Employee 3, a nurse aide, stated that she took the morning water temperatures earlier this morning, prior to showering residents. She explained that the facility never trained her on the procedure for checking water temperatures prior to showering residents, but she figured out the method on her own. She explained that there is a blue thermometer in the shower stall to measure the water temperature. When asked to demonstrate how she measures and records the water temperature obtained prior to showering residents, Employee 3, nurse aide, was observed looking at the blue thermometer but not placing the thermometer under the flowing water. She stated that the thermometer read 80 degrees Farenheit. She explained that she always makes sure the water is safe by testing it with her hand and asking residents if the water is comfortable. She stated, at the time of this interview, she had just completed Resident 13's shower. During an interview on April 10, 2024, at 9:33 AM, Employee 4, nurse aide, stated that he was trained to utilize a blue thermometer that was hanging in the shower. He stated that the water shower temperature is then recorded on the temperature log sheet. He stated that he was not aware of a temperature that was too high for the residents to be showered. He explained that he always asks the residents about their comfort with the water temperature and feels the water temperature prior to letting residents shower. During an observation on April 10, 2024, at the same time as the interview, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 22 of 29 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 04/12/2024 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility's [NAME] Wing shower room water temperature measured 128 Fahrenheit. The measurement was taken by Employee 4, nurse aide. During a resident group interview on April 10, 2024, at 10:00 AM, Resident 69 stated that when he independently takes showers, the water temperatures fluctuate from hot to cold. He explained that when the water becomes too hot, he points the shower handle away from his body. Resident 69 stated that he may have to wait up to two minutes before the water temperature is comfortable enough to resume showering with the water. Water temperatures were obtained in the bathrooms of the resident rooms the B unit (locked dementia unit) and common bathing/shower room on April 10, 2024, at approximately 10:30 AM: Resident rooms 216 & 217 -122.2 degrees Fahrenheit Resident room [ROOM NUMBER] (a four bedded room) 122.7 degrees Fahrenheit Resident room [ROOM NUMBER]/221- 133.8 degrees Fahrenheit Resident room [ROOM NUMBER]/225--128.8 degrees Fahrenheit Resident room [ROOM NUMBER]/226--129.7 degrees Fahrenheit Resident room [ROOM NUMBER] & 222--119.9 degrees Fahrenheit Resident room [ROOM NUMBER] & 211-- 134.6 degrees Fahrenheit Resident room [ROOM NUMBER] (a single room) - 127 degrees F, the cold water in the sink did not work at the time of the observation. Observation in Resident room [ROOM NUMBER] at this time, revealed Resident 12, who was alert and oriented was attempting to use the sink in her room to wash her hands. The resident confirmed that the cold water did not work but she was ok to use just the hot water. The surveyor redirected the resident another area to wash her hands with a safe water temperature at that time or perform hand hygiene. The B unit resident shower hot water temperature was 124.4 degrees Fahrenheit. There were 27 residents residing on the B unit locked dementia unit, all who utilized the shower on the unit for bathing and some utilized the sinks in their respective resident rooms. An observation April 10. 2024 at 9 AM in the resident common shower area on the west hall B unit revealed a clipboard with water shower temperature listings dated March 23, 2024 through April 5 , 2024. The documentation noted that all that all the water shower temperatures were noted to be exactly 100 degrees Fahrenheit. During an interview on April 10, 2024 at 9 AM Employee 1, a nurse aide, stated that she was routinely scheduled to work in the B unit (locked dementia unit). She stated that the hot water temperature at the sinks in the resident rooms on the unit has been really hot for a while. She stated that the unit shower water was also really hot. Employee 1 stated that the Director of Nursing (DON) told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 23 of 29 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 04/12/2024 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 0835 her to document 100 degrees Fahrenheit for every shower given despite the actual temperature obtained. Level of Harm - Minimal harm or potential for actual harm During an interview on April 10, 2024 at 9:05 AM, Employee 2, a nurse aide, stated that hot water in the resident room sinks and the common resident shower is very hot. She stated that the DON instructed her, after taking a shower water temperature, to document (on the designated shower temperature log, located in the shower room) 100 degrees Fahrenheit no matter what the actual temperature reads on the thermometer. Residents Affected - Some An interview with the Nursing Home Administrator at 1:30 PM on April 10, 2024, revealed that the NHA confirmed that the elevated hot water temperatures obtained and noted above were correct. He also verified that Resident 12 was at risk for burns due to the temperature of the hot water at the sink in the resident's room and the lack of running cold water at the sink at the time of the observation. He further stated that an unknown employee turned the cold water off underneath the sink in Resident 12's room, failed to tell maintenance of any issues, and did not turn the cold water back on for resident use. The NHA was unable to state how long the hot water temperatures were at an unsafe level. Immediate Jeopardy was called on April 10, 2024, due to the facility's failure to ensure that the environment for the residents on the [NAME] unit, the A and B (locked dementia unit) resident hallways was free of potential accident hazards in the form of elevated hot water temperatures. The job description of the Nursing Home Administrator dated, July 27, 2016, revealed, the primary purpose of the job position is to manage the facility in accordance with the current applicable federal, state and local standards, guidelines and regulations that govern long term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to out residents at all times. The Job Description for Direction of Nursing Services dated, February 23, 2023, revealed the purpose of the director of nursing is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the administrator and the Medical Director, to ensure the highest degree of quality care is maintained at all times. The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.12(a)(1) , revealed that the NHA and DON failed to fulfill the essential job duties for ensuring the safety of the residents and adherence to regulatory guidelines. Refer F689 28 Pa. Code: 201.18 (e)(1) Management 28 Pa. Code 211.12 (c) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 24 of 29 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 04/12/2024 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to conduct a facility wide assessment that accurately reflected the personnel and specific resources presently available and to identify those that are necessary to care for its current resident population. Findings include: At the time of the survey ending April 12, 2024, the facility had reviewed its facility assessment on June 3, 2023, to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations. The facility provided a facility assessment tool to the survey team on April 11, 2024. There was no documentation on the form that identified and addressed the needs of the locked B unit, Dementia/Memory care unit. The form did not include any focus on the care and needs of the 48 residents with documented diagnosis of Dementia/Alzheimers disease, including the 27 residents residing on the locked dementia unit. There was no addressed dementia care and dementia care needs of their current resident population in the facility assessment, and identified the available resources for making staffing and operating budget decisions while managing the resident census to ensure that the facility had the necessary staff resources to care for its resident population in a manner that met minimum licensure and certification standards. The facility assessment presented to the survey team during the survey ending April 12, 2024, did not include updated comprehensive data with respect to its current resident population and updated resources necessary to competently and safely care for the residents in the facility. Refer F 744 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(e)(1)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 25 of 29 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 04/12/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the statement of deficiencies from the survey ending February 15, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to ensuring that the facility environment was maintained in a safe, clean, comfortable, and homelike environment. Findings included: During an abbreviated complaint survey completed on February 15, 2024, deficient facility practice was identified under the requirement of safe, clean, comfortable, and homelike environment whereas 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). In response to the deficiency cited during the survey of February 15, 2024, the facility developed a plan of correction to include a quality assurance monitoring component to ensure that solutions were sustained. This plan was to be completed by March 19, 2024, and indicated that the following would be performed: The areas noted in the resident TV rooms on the East Side and [NAME] Sides, A and B Hallways, rooms [ROOM NUMBER] and their bathrooms, C-Hall shower room, A-Hall shower room, Small hole in C-Hall wall, C-Hall green floor molding and stained peeling paint on/ by exit door/frame, stained/discolored chair seat cushion of chairs in C-Hall exit corridor, room [ROOM NUMBER], 118, and 119, D-Hall laundry cart cover will be cleaned, painted, repaired or replaced as needed to address the deficiencies noted. The Environmental Services Director, Maintenance Director and their staff would be re-educated on the need to provide and maintain a clean and orderly environment. Both the Environmental Service Director and Maintenance Director with conduct rounds of the facility with the Nursing Home Administrator or designee weekly for 4 weeks and then monthly for 2 months to verify compliance. The results of the rounds would be reviewed at the month Quality Assurance meeting and any concern will be forwarded to the appropriate department manager to address immediately. This corrective active plan was to be in place by March 19, 2024. However, at the time of the revisit survey ending April 12, 2024, revealed that the facility failed to prevent a continuing quality deficiency under this same requirement whereas the facility failed to provide housekeeping services to to maintain a clean and orderly environment on four of the four nursing units (Nursing [NAME] A, [NAME] B, East C, and East D Hall). The facility's quality assurance monitoring plan failed to identify ongoing deficient practice with the facility's housekeeping and maintenance of a clean, sanitary and orderly environment. Refer F584 28 Pa. Code 201.18(e)(2.1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 26 of 29 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 04/12/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, the facility's infection control data, and infection control program and policies and staff interview, it was determined that the facility failed to maintain a comprehensive program to monitor and prevent infections in the facility. Residents Affected - Many Findings include: A review of the facility's current infection control policy provided during the survey ending April 12, 2024, revealed that it is the purpose of the facility Infection Prevention and Control Program is to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections and to improve antibiotic use. The facility adheres to the mission and goals set forth in the infection control plan. A review of the facility's compiled infection data since the last standard survey ending May 12, 2023, revealed that during the months from August 2023 through March 2024 multiple resident infections were identified each month. However, there was no documented evidence that the infection preventionist/designee had evaluated potential causative factors and tracked the infections for any potential patterns or trends and evidence of the the corresponding applicable interventions initiated to prevent occurrence of similar infections. The monthly infection tracking logs dated August 2023 through March 2024 included no descriptive information on the infections listed to include symptoms, culture or testing, organisms identified, completed treatment information or resolution dates. There was no indication that the limited infection data that the facility had compiled was then evaluated to determine what could be done to prevent the spread or recurrence of infection. The facility failed to demonstrate that its infection control program included, at a minimum, a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors following accepted standards and guidelines. Interview on April 11, 2024, at 10 AM with the facility Infection Control Nurse confirmed that the facility's current infection control program did not meet the intent of the requirements contained in the long term care regulations. 28 Pa Code 211.10 (a)(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: 395872 If continuation sheet Page 27 of 29 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 04/12/2024 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 0881 Implement a program that monitors antibiotic use. 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 clinical records and the facility's infection control policies and staff interview it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by one of 20 sampled residents (Resident 15). Residents Affected - Few Findings include: A review of the facility policy for Antibiotic Stewardship, dated as reviewed June 21, 2023, revealed that the plan was designed to facilitate compliance with state and federal regulations relating to infection control and antibiotic stewardship. It is the purpose of the facility Infection Prevention and Control Program is to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections and to improve antibiotic use. The facility adheres to the mission and goals set forth in the infection control plan. Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include dementia, chronic kidney disease stage 3 and was severely, cognitively impaired. A review of an RN Practitioner assessment of the resident dated March 15, 2024, revealed that a Chart review indicates {Resident 15} with multiple UTIs in the past, asked nursing to collect urine and dip is suspicious for UTI sent for U/A C&S (urinalysis and culture and sensitivity), initial urine appears suspicious for infection, collect U/A C&S via straight cath. The noted plan included Elevated white blood cell count, no clinical signs of infection, vital signs stable, collect U/A C&S (urinalysis and culture and sensitivity). The RN practitioner ordered a urinalysis and culture and sensitivity (report to indicate what antibiotic will treat the infection) to rule out a urinary tract infection at that time and ordered Augmentin (an oral antibiotic medication) 500/125 mg, one by mouth twice a day for 5 days for UTI (urinary tract infection) on March 15, 2024. Nursing documentation dated from March 1, 2024, through March 15, revealed no documentation that the resident was displaying signs or symptoms of a UTI. A review a nurses note dated March 19, 2024, at 1:31 PM revealed that a new order was noted from the CRNP to discontinue Augmentin, and start Ceftin 250 mg BID x 5 days. An RN Practitioner assessment dated [DATE], revealed Examined bedside follow-up, reviewed U/A C&S, mother suspicious of UTI will start Ceftin 250 mg twice daily and encourage fluids. The CRNP order dated March 19, 2024, was noted for Ceftin 250 (an oral antibiotic) mg twice daily, for 5 days for UTI. A review of the resident's March 2024 medication administration record (MAR) revealed that Resident 15 received Augmentin 500/125 mg by mouth on March 17th, two doses, March 18th two doses and one dose on March 19th. According to the March 2024 MAR, Augmentin was discontinued on March 19, 2024, and Ceftin 250 mg, by mouth, twice daily was given as prescribed until March 24, 2024 (10 doses). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 28 of 29 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 04/12/2024 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a culture and sensitivity results dated March 21, 2024, revealed that Resident 15's urine contained greater than 100, 000 colonies/ml Klebsiella pneumonae bacteria. The corresponding sensitivity report did not include the initial antibiotic prescribed for the resident, ( Augmentin ). There was no corresponding prescriber documentation to indicate the rationale for initiating Augmentin, prior to receipt of the results of the C & S, and then discontinuing Augmentin after five doses, then starting Ceftin, prior to receiving the results of the C & S. There was no evidence at the time of the survey of a functioning antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use to prevent unnecessary antibiotic use. During an interview April 11, 2024, at 1 P.M., the Director of Nursing confirmed that the resident received unnecessary doses of antibiotics that was not consistent with antibiotic stewardship. Refer F757 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services 28 Pa. Code 211.2 (d)(8) Medical Director 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 29 of 29