Health inspection·February 14, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's abuse prohibition policy, clinical records, select investigative reports and staff interviews, it was determined the facility failed to assure that one resident (Resident 40) was free from physical abuse perpetrated by another resident (Resident 81) out of 23 sampled residents. Findings include: A review of facility policy titled Abuse Policy, last reviewed by the facility on November 1, 2024, revealed it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 40's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia (a group of symptoms that causes a decline in memory and thinking and interferes in daily life) and generalized anxiety disorder (a disorder that is characterized by excessive worry and nervousness. A review of the Resident 40 s admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 11,2024, indicated that the resident was moderately impaired cognitively with a BIMS (Brief Interview for Mental Status - a tool to assess cognition) score of 9 (8-12 represents moderate cognitive impairment). A review of Resident 81's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia (a group of symptoms that causes a decline in memory and thinking and interferes in daily life) and Legal Blindness (severe vision loss). A review of the Resident 81's admission Minimum Data Set, dated [DATE], indicated that the resident was severely impaired cognitively with a BIMS score of 4 (0-7 represents severe cognitive impairment). A review of Resident 81's progress notes from December 2024 through January 2025 revealed the resident displayed behaviors of agitation, aggressive behavior, verbal abuse with staff and other residents, physically abusive to staff, physical and verbally aggressive with care, biting and spitting at staff, and refusing medications. During these displayed behaviors, the facility staff indicated they Page 1 of 18 395872 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would redirect the resident. However, due to the resident's cognitive impairment the resident is unable to follow redirection. A review of Resident 81's resident current plan of care initiated on November 12, 2024, revealed the resident had increased behaviors related to unspecified dementia with a goal to be able to state her concerns and have her needs met. Further review of the resident's care plan for increased behaviors related to dementia revealed interventions such as Ativan (antianxiety medication) 0.5 mg by mouth every 6 hours as needed, encourage activities of interest, encourage family involvement, explain how her current behavior is detrimental, refer to psychiatry if needed. The resident's plan of care failed to identify the resident's specific behaviors she was exhibiting. Further the facility failed to develop and implement person centered interventions to deter the resident's verbally and physically aggressive behaviors. A review of nursing documentation dated January 23, 2025, at 7:10 PM revealed Resident 81 was in an altercation with Resident 40. Resident 81 and struck Resident 40 with a closed hand in the chest while Resident 40 was sitting in her wheelchair. A review of a facility investigation dated January 23, 2025, at 7:00 PM revealed Resident 81 was witnessed to have hit while Resident 40 in the chest while she was sitting in her wheelchair. It was indicated both residents were separated at that time. Resident 40 was assessed with no injuries noted. Resident 81 was placed on every 15-minute checks. A review of Employee 7's witness statement dated January 23, 2025, revealed the employee was coming out of another resident's room and heard yelling. The employee indicated she walked into the TV room on the A hall and witnessed Resident 81 hit Resident 40. The employee stated Resident 81 then grabbed Resident 40 by the shirt in the chest area. The employee indicated she moved resident 40 into the hall away from Resident 81. The employee stated Resident 81 continued to be irritated and yelling I will hit you again. The facility failed to identify and implement appropriate interventions for a resident with known aggressive behaviors resulting in of Resident 40 being hit in the chest. An interview with NHA (Nursing Home Administrator) on February 14, 2025, at approximately 9:45 AM confirmed the facility failed to ensure of Resident 40 was free from physical abuse perpetrated by Resident 81. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services 395872 Page 2 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, select facility investigative reports, select facility policies, and staff interview, it was determined the facility failed to provide meal tray set-up assistance to ensure food was cut in bite size pieces to promote safe swallowing for one of 23 residents sampled (Resident 76). Residents Affected - Some Findings include: Review of the facility Assistance with Meals Policy dated November 1, 2024, indicated that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. All residents will be encouraged to eat in the dining room. Facility staff will serve resident trays and will help residents who require assistance with eating. Review of the facility LifeVac Policy (non-powered, non-invasive, single use only airway clearing device developed for resuscitating a victim with an airway obstruction) dated November 1, 2024, indicated the LifeVac can be utilized when traditional basic life-saving methods, such as the Heimlich maneuver (first-aid technique that uses abdominal thrusts to help someone who is choking), have been unsuccessful in clearing an airway obstruction. Review of Resident 76's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and anxiety. A physician order dated October 16, 2023, revealed an order for a Regular diet. Review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 8, 2024, indicated the resident had a BIMS score of 3 (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 0-7 indicates severe cognitive impairment), required supervision or touching assistance with verbal cues or touching/steadying assistance for feeding, did not have a swallowing disorder, and was not on a mechanically altered diet (diet that modifies food texture to make foods easier to chew and swallow). A review of an Occupational Therapy Discharge summary dated [DATE], revealed the resident required setup (cutting up food in appropriate bite-size pieces, ensuring all items within reach, lids removed, containers opened, and condiments added) and clean-up assistance with meals. Review of the resident's November 2024 Task Documentation Survey Report revealed the resident was independent for eating with setup help only. Review of the resident's care plan initially dated September 21, 2023, and revised May 11, 2024, indicated the resident has a concern related to dementia and poor safety awareness. Interventions included for staff to adjust the resident's diet to accommodate chewing, swallowing, or eating issues to maximize independence and nutritional intake. Further review of the resident's care plan failed to address the extent of meal assistance the resident required for meals. 395872 Page 3 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On November 18, 2024, at 1:30 PM and 4:31 PM, nursing note documented that Resident 76 required intervention using the LifeVac to dislodge a piece of chicken, the size of a fifty-cent coin. While in the dining room the resident was observed holding his neck, with unclear speech and blue lips. The resident's oxygen saturation was 91% on room air (95-100% is [NAME], 90-92 % is considered low oxygen) and a diet modification to mechanical soft (foods are soft easy-to-chew and mashed or ground) was implemented, with a speech therapy referral placed. Review of facility investigative documentation dated November 18, 2024, confirmed the resident was at the lunch table eating when he started choking. Employee 4 (LPN) utilized LifeVac, and resident dislodged a piece of chicken. Further review of the investigation indicated that Resident 76 was seen two minutes prior to the incident. There was no indication that staff provided setup help to the resident as required to ensure the resident's food was cut into bite size pieces. Review of a Speech Therapy Evaluation dated November 19, 2024, noted the resident was referred for a dysphagia (difficulty swallowing) evaluation to determine the safest, least restrictive diet texture post a choking incident on November 18, 2024, while consuming regular chicken. Staff utilized LifeVac to clear bolus from airway. Per staff, resident had upper and lower dentures in place, yet staff questions if resident's meat was cut into small bites as the piece, he was able to expel was quite large. Review of a Speech Therapy Discharge summary dated [DATE], noted the resident's swallow skills are within full limits. Resident discharge recommendation for Regular texture diet with thin liquids. To facilitate safety and efficiency it is recommended the resident use the following strategies during oral intake: general swallow techniques/precautions, bolus size modifications, and rate modification along with upright posture during meals. A nurses note dated January 12, 2025, at 7:22 PM noted the resident had a very significant coughing episode. Resident was able to dislodge a large piece of meat with staff assistance of manually forcing food out by Employee 6 (LPN). The diet was downgraded to dysphagia advanced with ground meat pending further speech therapy evaluation Review of the menu revealed that at the time of the incident Resident 76 was served Italian baked chicken. Staff meeting minutes (January 21 and 23, 2025) indicated that staff were educated on ensuring food is cut into small, manageable pieces for residents requiring such assistance Interview with the foodservice director on February 14, 2025, at 9:00 AM confirmed that for a regular diet, the Italian baked chicken served to Resident 76 was a whole three-ounce boneless chicken breast. There was no documented evidence that Resident 76 was provided tray setup assistance, or that the Italian baked chicken was cut into bite size pieces as required. Interview with the director of nursing (DON) on February 14, 2025, at 10:00 AM confirmed that Resident 76 required tray setup assistance. The DON confirmed that the facility failed to provide the necessary staff tray set up assistance to the resident to ensure food was cut by staff into bite size pieces to promote safe swallowing. 395872 Page 4 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0677 Level of Harm - Minimal harm or potential for actual harm The facility failed to provide essential tray setup assistance, including ensuring that Resident 76's food was cut into bite-sized pieces. This failure directly contributed to multiple choking incidents, necessitating the use of a LifeVac, speech therapy intervention, and dietary modifications 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Residents Affected - Some 395872 Page 5 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of clinical records and the facility's activity calendar, and interviews with staff, it was determined the facility failed to provide an individualized activities program designed to meet the specific functional needs, abilities, and preferences for residents with dementia and/or sensory deficits for five residents (Residents 15, 46, 96, 65, and 51) out of 23 sampled residents. Residents Affected - Some Findings include: On February 13, 2025, at 10:35 AM, an observation was conducted in the day room across from the C/D nurses' station. Five residents (Residents 15, 46, 96, 65, and 51) were seated in the room. The television was on; however, none of the residents appeared to be watching or engaged with the program. No staff member was present, and none of the residents were conversing or otherwise engaged in meaningful activities. According to the February 2025 activities calendar, a scheduled Ladies Group was taking place in the main dining room; however, the female residents in the day room were not participating in the scheduled activity. A review of Resident 15's clinical record revealed admission to the facility on October 3, 2020, with diagnoses to include bilateral sensorineural hearing loss (hearing loss affecting both ears due to damage of the inner ear), and bilateral cataracts (occurs when the lens in both eyes becomes cloudy). The clinical record indicated that she is moderately cognitive impairment and requires assistance from staff for all care. Her documented activity preferences include listening to music, being around animals, keeping up with the news, spending time outdoors, and participating in religious services. However, a review of her activity participation log for the past 75 days revealed only one recorded activity on December 29, 2024, when she had her nails painted while in the day room. No additional documented record of Resident 15's activity participation was provided. A review of Resident 46's clinical record revealed admission to the facility on December 4, 2017, with diagnoses to include Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions) and cerebrovascular disease (or a stroke - when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel). The clinical record indicated he is severely cognitively impaired and is dependent on staff for all care. His activity preferences include reading books, newspapers or magazines, listening to music, participating in group activities, and attending religious services. A review of his activity participation log for the past 75 days documented engagement only four times: December 19, 2024 - attended a live music program December 25, 2024 - received a Christmas gift January 13, 2025 - received a one-to-one visit from staff February 10, 2025 - attended a live music program No additional documented participation in activities was found. 395872 Page 6 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 96's clinical record revealed admission to the facility on January 21, 2025, with diagnoses to include vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients), and repeated falls. The clinical record indicated that he is severely cognitively impaired and is dependent on staff for all care. The clinical record also indicated that he enjoys reading books, newspapers or magazines, listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, participating in favorite activities, and spending time outdoors. A review of his activity participation log for the past 24 days showed only two documented instances of engagement: January 24, 2025 - visited by the Director of Activities for an activities assessment February 10, 2025 - invited to live entertainment but declined participation No further engagement was recorded. A review of Resident 65's clinical record revealed admission to the facility on September 21, 2023, with diagnoses to include Alzheimer's disease, and Down Syndrome (also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is typically associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features. The average IQ of a young adult with Down syndrome is 50, equivalent to the mental ability of an 8- or 9-year-old child). The clinical record indicated she is severely cognitively impaired and is dependent on staff for all care. The clinical record also indicated due to communication barriers, activity preferences were not documented as her family or significant others were unavailable. A review of Resident 65's activity participation log for the past 75 days revealed that on December 16, 2024, that while waiting for her turn with the beauty shop, she was provided with a baby doll to hold because she loves baby dolls when she sees other residents with them. She enjoyed holding and talking to her baby while she waited. No additional documented record of Resident 65's activity participation was provided. A review of Resident 51's clinical record revealed admission to the facility on August 25, 2018, with diagnoses to include paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and bilateral sensorineural hearing loss. The clinical record indicated she is severely cognitively impaired and is dependent on staff for all care. The clinical record indicated she enjoys listening to music, being around animals such as pets, participating in favorite activities, spending time outside and participating in religious activities or practices. A review of her activity participation log for the past 75 days revealed only one recorded activity on January 22, 2025, when an activities staff member visited her with a baby doll and pacifier, which she held and smiled at. No additional documented record of Resident 51's activity participation was provided. A review of clinical records and activity participation logs demonstrated the facility failed to provide consistent and individualized activities tailored to the residents' cognitive and sensory needs. Residents with documented preferences for music, socialization, sensory stimulation, and religious activities were not routinely engaged in meaningful or personalized activities. 395872 Page 7 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0679 Level of Harm - Minimal harm or potential for actual harm During an interview with the Activities Director on February 13, 2025, at approximately 1:30 PM, she acknowledged that the Activities Department had been short-staffed, resulting in difficulty providing one-on-one visits and engagement for residents with dementia and sensory deficits. She confirmed that these residents were not receiving adequate or individually designed activities programming to meet their specific needs, abilities, and preferences. Residents Affected - Some The facility failed to develop and consistently implement an activities program that meets the functional needs, abilities, and preferences of residents with dementia and/or sensory deficits. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(ii) Medical records 395872 Page 8 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure a physician-ordered fluid restriction was maintained for one resident receiving dialysis (Resident 13) out of 23 sampled. Residents Affected - Few Findings include: A review of a facility policy titled Encouraging and Restricting Fluids last reviewed by the facility on November 1, 2024, revealed the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. The policy stated, Verify that there is a physician's order for this procedure and review the resident's care plan and/or assignment sheets to assess for any special needs of the resident. The procedure stated to follow the specific amount of fluids ordered by the physician concerning for fluid intake or restrictions. A review of the clinical record revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and end-stage kidney disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) with dependence on hemodialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 5, 2025, revealed that Resident 13 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). A physician's order dated January 8, 2025, was noted for the resident to be maintained on a 1000 milliliter (ml) fluid restriction with the following breakdown of the fluid distribution for a total of 340 ml of fluids to be provided by nursing each day and a total of 660 ml of fluids to be provided by dietary each day. A review of Resident 13's fluid intake task report (an electronic record that summarized planned resident centered tasks completed by nursing) revealed that the system was set for a 1500 ml fluid restriction, conflicting with the physician's order. A review of documented daily fluid intake for January and February 2025 showed multiple instances where Resident 13 exceeded the 1000 ml fluid restriction: January 17, 2025, 1340 ml January 21, 2025, 1350 ml January 27, 2025, 1240 ml January 28, 2025, 1440 ml 395872 Page 9 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0692 January 29, 2025, 1120 ml Level of Harm - Minimal harm or potential for actual harm January 30, 2025, 1820 ml February 1, 2025, 1040 ml Residents Affected - Few February 3, 2025, 1350 ml February 5, 2025, 1020 ml February 6, 2025, 1560 ml February 10, 2025, 1500 ml February 11, 2025, 1320 ml Interview with the Director of Nursing on February 13, 2025, at 2:15 PM confirmed that the facility had failed to follow the physician's order for the 1000 ml fluid restriction to ensure compliance with the prescribed fluid restrictions which resulted in Resident 13 exceeding her fluid intake. The facility failed to ensure adherence to Resident 13's physician-prescribed fluid restriction, as evidenced by repeated instances of excessive fluid intake documented in the facility records, and not complying with the physician's order of 1000 ml, instead following the facilities task report of 1500 ml which was inconsistent with the prescribed requirement. 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(ix) Medical records 395872 Page 10 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of select facility policy, test tray results, and resident and staff interviews, it was determined the facility failed to serve meals that were palatable and at a safe and appetizing temperature for 7 out of 23 residents sampled (Residents 44, 201, 38, 16, 88, 54 and 34). Residents Affected - Some Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Review of the facility Temperatures Policy dated November 1, 2024, indicated that all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. Take temperatures often to monitor for safe temperature ranges at or below 41 degrees Fahrenheit for cold foods and at or above 135 degrees Fahrenheit for hot foods. During a group interview with six alert and oriented residents on February 12, 2025, at 10:30 AM, all six residents in attendance (Residents 44, 201, 38, 16, 88, and 54) stated that the hot food temperatures are frequently cold. Resident 38 stated that the food is cold every day, at all meals. Resident 88 stated that the food is lukewarm at best. During an individual interview with Resident 34 on February 11, 2025, at 12:30 PM, the resident stated, The hot foods are never hot, always cold. The resident further confirmed that food was often cold during all mealtimes. A test tray evaluation was conducted on the East D Wing Nursing Unit on February 12, 2025. The test tray arrived on the Nursing Unit at 12:14 PM. The meal served was chicken with gravy and waffle, marinated cold green-bean salad, a chocolate-chip bar, milk, and coffee. At 12:24 PM, after the last resident was served, food temperatures were recorded: Chicken with gravy and waffle: 102.5°F (Below the required 135°F minimum) Coffee: 138°F The chicken with gravy tasted cold and was not palatable at the temperature it was served. The waffle was soggy and not toasted further reducing the palatability of the meal. An interview with the foodservice director on February 12, 2025, at approximately 12:45 PM confirmed that food must be palatable and served at safe and appetizing temperatures. The director acknowledged the test tray results did not meet the facility's policy or regulatory requirements. 28 Pa. Code 201.18 (e)(3) Management 395872 Page 11 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined the facility failed to provide adaptive dining equipment as required and prescribed for one resident out of 23 sampled (Resident 46). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses to include early onset Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions), and cerebrovascular disease (or stroke - when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel). Review of Resident 46's plan of care dated November 17, 2021, indicated that the resident had a nutritional problem or a potential nutritional problem due to gastroesophageal reflux (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach. Foods containing tomato, such as spaghetti sauce, salsa, or pizza, spicy foods, such as those containing chili or curry, and citrus foods could trigger symptoms such as acid reflux, difficulty swallowing, chest pain, and a persistent dry cough), hypertension (high blood pressure), and dysphagia (difficulty swallowing food or liquid) and receives a mechanically altered diet (foods that are easy to swallow because they are blended, chopped, grounded or mashed so that they are easy to chew and swallow). As part of the dietary interventions, the resident was prescribed: Regular, puree texture food, thin consistency for drinks; fortified cereal at breakfast; provide a maroon pediatric spoon (an adaptive spoon with a narrow, shallow bowl) for feeding to facilitate small bolus size (semi-solid mass of food) to increase safety for all meals and snacks. A review of the physician's orders, revised on January 3, 2025, confirmed that the resident was to use a maroon pediatric spoon for all meals and snacks to promote safe swallowing. Observation of the lunch meal on February 11, 2025, at 1:20 PM revealed Resident 46, served his meal with a white plastic spoon instead of the prescribed maroon spoon A staff member was observed feeding the resident using the incorrect utensil. On February 12, 2025, at 1:19 PM, another observation revealed the resident, again, was served lunch with a white plastic spoon. Employee 1 (nurse aide) was observed feeding the resident without using the prescribed maroon spoon. Interview with Employee 1 on February 12, 2025, at 1:20 PM confirmed the maroon spoon was not provided on the place setting nor was it being utilized at the time of the observation. During an interview on February 13, 2025, at approximately 1:45 PM, the Director of Rehab acknowledged that the facility failed to provide the required adaptive dining equipment as ordered by the physician, increasing the risk of choking and compromising the resident's safety. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 395872 Page 12 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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. Residents Affected - Many 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). Observation during the initial tour of the food and nutrition services department with the foodservice director (FSD) conducted on February 11, 2025, at 9:20 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: A lidded garbage can next to the handwashing sink was unable to close due to being overfilled with paper towels and waste, posing a contamination risk in a food preparation area. A visible build-up of dirt and debris was noted beneath the tray line and steam table, creating unsanitary conditions in a high-use food preparation area. The kitchen floor perimeter showed signs of heavy soiling, which could harbor bacteria and pests. The backsplash on the stove had accumulated grease and food stains, representing a potential source of cross-contamination. Observation of the walk-in cooler revealed three cases of cottage cheese being stored on a shelf in near contact with the ceiling limiting airflow and compromising temperature regulation as acknowledged by the FSD. Four thawed eight-ounce nutritional juice drinks and three thawed four-ounce nutritional shakes lacked appropriate thaw and discard dates. According to manufacturer guidelines, these items must be used within 14 days of thawing. Three thawed four-ounce nutritional desserts were not labeled with discard dates. Manufacturer guidelines require consumption within 5 days of thawing. Four bags of frozen mixed vegetables in the walk-in freezer were undated, preventing proper monitoring of storage times. Three cases of assorted food items were stored directly on the floor of the dry storage room, contrary to professional standards that require food to be stored at least 6 inches off the floor to prevent contamination. 395872 Page 13 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation of the tray line in the food and nutrition services department during the lunch meal on February 12, 2025, at 12:05 PM revealed the following: Both Employee 2 (cook) with a goatee (facial hair that only covers the chin) and the FSD with a beard were observed handling food without wearing proper beard covers, failing to meet hygiene standards and increasing the risk of contamination. Observation of the dish room area in the food and nutrition services department on February 14, 2025, at 9:30 AM revealed six thermal beverage mugs, labeled as clean, had visible coffee stains on their interior surfaces, indicating inadequate cleaning practices and a failure to meet sanitation standards for food service equipment. Interview with the foods service director (FSD) at the time of the observations confirmed that all food and beverages must be stored and thawed following manufacturer guidelines and facility protocols to prevent contamination, and the dietary department must be maintained in a sanitary condition to comply with federal food safety regulations. 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services 395872 Page 14 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

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 interview and review of professional literature, the facility's assessment, facility provided documentation, and review of the medical, psychiatric, and mental health conditions of the resident census, it was determined the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified the specific resources necessary to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Continued review revealed, the assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. Further review revealed, the assessment of the resident population should also contribute to identifying additional needs for residents, such as the physical space, equipment, assisted technology, individual communication devices, or other material resources that are needed to provide the required care and services to residents. Review of the Facility Assessment, last reviewed by the facility on January 31, 2025, failed to accurately identify the specific needs and services required by the various subsets and characteristics of the resident population. The facility assessment did not incorporate critical factors such as specific staff competencies, equipment needs, and services required to meet the individual and collective needs of the resident population. Review of the facility's Resident Matrix (list of all residents in the facility), dated February 11, 2025, revealed a total census of 98 residents. Of the 98 residents, the Matrix identified 46 residents with an Alzheimer's or dementia diagnosis. A review of the facility document titled Diagnosis Report dated February 14, 2025, identified residents currently receiving psychiatry and/or psychology services. Of the 98 residents in the facility, 26 residents were currently identified as receiving psychiatric and/or psychological services. The Facility Assessment presented to the survey team indicated there were no residents with behavioral health needs who would need special treatments and conditions despite the characteristics of the current resident population. The facility assessment failed to accurately reflect the current population in the facility and the behavioral health and dementia care needs of the residents to ensure resident safety. The Facility Assessment failed to include the resources needed, including an evaluation of the overall number of facility staff to include dietary and activity staff; and contracted staff to include agency nursing staff, and the capabilities needed to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. 395872 Page 15 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Facility Assessment failed to include the physical resources needed, including resident care equipment, medical supplies and non-medical supplies, to provide the required care and services to meet each resident's needs. During an interview on February 14, 2025, at 9:30 AM, the Nursing Home Administrator acknowledged the Facility Assessment did not contain all the required information needed to meet regulatory requirements and address the specific needs of the resident population. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2) Management 395872 Page 16 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of select facility policy, the facility's infection control log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility and further failed to ensure that staff followed proper infection control techniques while passing medications to three of three residents (Residents 6, 22, and 32) on the A Hall nursing unit. Residents Affected - Some Findings included: A review of facility policy titled Infection Prevention and Control Program last reviewed by the facility on November 1, 2024, indicated the Infection Prevention and Control Program (IPCP) is established and maintained to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The elements of the IPCP consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. An observation on February 12, 2025, at 8:22 AM revealed Employee 3 RN (registered nurse) was administering morning medications to Resident 6 on the A Hall nursing unit, Employee 3 was removing the medication Folic Acid 1 mg (a vitamin) from the medication card, and the employee used her bare hand without performing hand hygiene to remove the pill from the medication card, touching the pill with her ungloved hand and without performing hand hygiene or donning gloves, and placed it in Resident 6's medication cup. The employee then proceeded to administer the medications to Resident 6. The employee failed to wash her hands after administering the medications. An observation on February 12,2025, at 8:35 AM revealed Employee 3 RN was administering medications to Resident 22 on the A hall unit, when the employee was removing the medication Tamsulosin 0.4 mg ( a medication that relaxes bladder muscles) from the medication card using her bare hand without performing hand hygiene to remove the medication from the medication card, touching the pill, with her ungloved hand, and without performing hand hygiene or donning gloves, and placing it in Resident 22's medication cup. The employee proceeded to administer the medications to Resident 22. The employee failed to wash her hands after administering the medications. Further observation on February 12, 2025, at 8:43 AM revealed Employee 3 RN was administering medications to Resident 32 on the A Hall unit when the employee was removing Buspirone 5 mg (a medication used to treat anxiety) from the medication card, using her bare hand without performing hand hygiene, touching the pill with her ungloved hand without performing hand hygiene or donning gloves, and placing it in Resident 32's medication cup. The employee proceeded to administer the medications to Resident 32. The employee failed to wash her hands after administering the medications. An interview with the Director of Nursing on February 12, 2025, at approximately 1:00 PM confirmed that Employee 3 failed to follow proper infection control measures prior to the administration of these medications. A review of facility infection control logs for April 2024 through February 2025 revealed the facility did not have accurate tracking of infections for the months of August 2024 and September 2024. An Interview with the Infection Preventionist (IP) on February 14, 2025, at 9:45 AM verified that she became the facility's IP on September 23, 2024, and at the time of her hire, there was no current 395872 Page 17 of 18 395872 02/14/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some IP currently working in the facility. The IP revealed the infection control tracking logs were not completed for August 2024 through September 2024. An interview with the Nursing Home Administrator (NHA) on February 14, 2025, at approximately 10:45 AM confirmed that the facility's previous IP stopped working on August 30, 2024, and the new IP did not start until September 23, 2024. The NHA confirmed the facility infection control logs were not complete and failed to maintain a comprehensive program to monitor and prevent infections. 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. The facility failed to ensure the implementation of a comprehensive infection prevention and control program designed to prevent, identify, investigate, and manage infections and communicable diseases across all residents, staff, and visitors, thereby placing residents at increased risk for healthcare-associated infections (HAIs). 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. 28 Pa. Code 211.10(c)(d) Resident care policies. 395872 Page 18 of 18