Health inspection·October 15, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few During an interview on [DATE], at 1:00 PM, Employee 1 stated she was assisting other residents in the activity room and did not recall whether Resident CR1 had her walker in the room, stating probably not because the resident was seated in the recliner. A review of facility investigative documentation and nursing notes dated [DATE], at 8:05 AM revealed the resident was being assisted by Employee 2 (Nurse Aide) from her bed to a standing position when she leaned forward and fell into the wall. The Registered Nurse (RN) Supervisor was notified. The resident was found face down between the bed and wall with her right arm under her body and a laceration (deep cut) noted to the right temple area (side of the head) with blood surrounding the head and face. Documentation indicated the resident was unresponsive for three minutes before responding to verbal stimuli. Resident CR1 indicated she had pain in her right arm and was noted to have a hematoma (blood underneath the skin) to her right wrist emergency medical services were called, and the resident was transported to the hospital. Education was provided at that time to Employee 2 (Nurse Aide) regarding using proper assistive devices when transferring a resident. A written witness statement dated [DATE] (no time indicated) revealed Employee 2 (Nurse Aide) stated Resident CR1 Sat up on the side of the bed. She was going to the bathroom. I was with her when she stood up. She pulled on the right side of her night gown. She leaned forward, fell face first on the floor, hitting her head on the wall. I got Employee 3 (LPN) right away. During an interview on [DATE], at 2:00 PM Employee 2 (Nurse Aide) stated she was performing morning care for Resident CR1 on the morning of [DATE]. She explained that she assisted the resident to a seated position on the edge of the bed and stood her up by herself. Employee 2 stated the resident began to pull on her gown, leaned forward, and fell into the wall next to the bed. Employee 2 stated she was aware the resident utilized a roller walker for transfers and ambulation and that the walker was not in the room at the time of the fall. She further stated she believed the resident was an assist of one with a roller walker and could not remember if she reviewed the electronic Kardex (the facility's electronic care assignment system used to identify resident care needs) prior to providing care that day. A written witness statement dated [DATE], at 10:50 AM from Employee 3 (LPN) documented that upon entering Resident CR1's room, the resident was lying prone (face down) on the floor with her head facing away from the nurse, positioned with her head toward the mirror and her feet toward the bed. A copious (plentiful) amount of blood was noted surrounding the resident's head. The Registered Nurse (RN) Supervisor was immediately notified. During an interview on [DATE], at 1:45 PM Employee 3 (LPN) stated that Resident CR1's first fall had occurred on [DATE], when therapy staff were not on duty. She stated that nursing staff implemented an interim increase in the resident's assistance level following that fall, pending therapy evaluation. Employee 3 stated that the physician was contacted after the [DATE] fall and issued a new order for the updated assistance level of two persons for assistance and ambulation with rollator walker. A review of hospital documentation dated [DATE], revealed the resident sustained a 7 centimeter (cm) scalp laceration that was closed with 5 sutures and a CT scan (computed tomography scan, a specialized X-ray imaging test producing detailed internal images) identified an acute right sided subdural hematoma (a collection of blood between the brain and its outer covering) with mass effect (pressure on brain tissue) and an 8 millimeter (mm) midline shift (displacement of the brain from its normal position). The resident was admitted to the trauma intensive care unit (TICU) with the subdural hematoma, brain swelling and compression, right hand contusion, and left knee and thigh ecchymosis (skin discoloration from bleeding under the skin). The resident returned to the facility on [DATE], and on [DATE], experienced an episode of unresponsiveness and a change in condition. The resident was hospitalized and returned on [DATE]. Documentation indicated the resident's condition continued to decline. Hospice services were initiated on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 2 of 5 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 10/15/2025 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 - Actual harm [DATE], and the resident expired (died) on [DATE], at 9:45 PM. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at approximately 4:00 PM. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 3 of 5 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 10/15/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of controlled drug records and select facility policy and staff interview, it was determined the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for two of 10 residents sampled (Resident 2 and 3). Findings include: A review of the facility's Medication Administration policy reviewed November 2024 revealed that medications are prepared only by licensed nursing staff, medical staff, pharmacy or other personnel authorized by state laws and regulations to prepare medications. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. Administration of the medication is documented immediately after it is given.Clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses of dementia (a progressive disorder causing memory loss and impaired judgment), anxiety and mood disorder. A quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated September 4, 2025, indicated the resident was severely cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 3 a score of 0-7 indicates severe cognitively impairment), required assistance for activities of daily living and received antianxiety medication. A physician's order dated September 8, 2025, directed administration of Ativan 0.5 mg (an anti-anxiety medication) by mouth every 6 hours as needed (PRN) for anxiety. The resident's September 2025 individual resident-controlled substance record (a prescription drug that is regulated by federal and state laws because it has the potential for abuse dependence or addiction) accounting for Resident 2's supply of the controlled drug, and nursing staff's removal of doses for administration of Ativan 0.5 mg revealed that nursing staff signed out doses of the controlled medication for administration to the resident on the following dates and times: September 12, 2025, at 2:00 PMSeptember 15, 2025, at 3:00 PMSeptember 16, 2025, at 2:30 PMSeptember 18, 2025, at 4:00 PMSeptember 20, 2025, at 8:00AMSeptember 21, 2025, at 8:00 AMSeptember 24, 2025, at 9:00 AMSeptember 25, 2025, at 1:00 PMSeptember 26, 2025, at 10:00 AMReview of the corresponding September 2025 MAR (medication administration record) did not contain documentation showing those medications were administered as ordered. Clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses of dementia and anxiety. An annual MDS dated [DATE], revealed that Resident 3 was severely, cognitively impaired with a BIMS score of 3 and required assistance for activities of daily living and received antianxiety and pain medication. The resident had a physician order dated May 10, 2025, for Ativan 0.5 mg (an antianxiety medication) one tablet by mouth every 6 hours as needed for anxiety/restlessness. The resident's August 2025 individual resident-controlled substance record accounting for Resident 3's supply of the controlled drug, and nursing staff's removal of doses for administration of Ativan 0.5 mg revealed that nursing staff signed out doses of the controlled medication for administration to the resident on the following dates and times: August 1, 2025, at 12:00 PMAugust 3, 2025, at 3:00 PMAugust 9, 2025, at 2:30 PMAugust 15, 2025, at 9:00 AMAugust 18, 2025, at 8:00 AMAugust 19, 2025, at 10:00 PMAugust 25, 2025, at 10:00 PMAugust 27, 2025, at 1:00 PM A review of the corresponding August 2025 MAR, the above noted doses were not signed out on the medication administration record (MAR) showing those medications were administered to the resident as ordered. The resident's September 2025 individual resident-controlled substance record accounting for Resident 3's supply of the controlled drug, and nursing staff's removal of doses for administration of Ativan 0.5 mg revealed that nursing staff signed out doses of the controlled medication for administration to the resident on the following dates and times: September (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395872 If continuation sheet Page 4 of 5 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 10/15/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 1, 2025, at 1:00 PMSeptember 2, 2025, at 12:00 PMSeptember 3, 2025, at 12:00 AMSeptember 8, 2025, at 8:30 PMSeptember 10, 2025, at 1:00 PMSeptember 12, 2025, at 10:41 AMSeptember 15, 2025, at 8:00AMSeptember 20, 2025, at 1:00 PMSeptember 22, 2025, at 9:00 PMSeptember 23, 2025, at 11:00 PMSeptember 24, 2025, at 8:00 AMSeptember 24, 2025, at 6:00 PMSeptember 26, 2025, at 7:45 AMSeptember 27, 2025, at 3:20 PMSeptember 28, 2025, at 7:00 PMSeptember 30, 2025, at 11:45 PMA review of a September 2025 MAR, the above noted doses were not signed out on the medication administration record (MAR) showing those medications were administered to the resident as ordered. The residents' October 2025 individual resident-controlled substance record accounting for Resident 3's supply of the controlled drug, and nursing staff's removal of doses for administration of Ativan 0.5 mg revealed that nursing staff signed out doses of the controlled drug for administration to the resident on the following dates and times: October 5, 2025, at 8:00 AMOctober 10, 2025, at 9:00 AMOctober 12, 2025, at 12:00 AM A review of an October 2025 MAR, MAR, the above noted doses were not signed out on the medication administration record (MAR) showing those medications were administered to the resident as ordered. During an interview October 15, 2025, at 4:00 PM, the Director of Nursing confirmed the above inconsistencies between the controlled drug records and medication administration records. The above noted doses of the antianxiety medication were documented as given on the narcotic reconciliation record; however, they were not signed out as administered on the MAR. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.10 (c) Resident care policies. Event ID: Facility ID: 395872 If continuation sheet Page 5 of 5