Health inspection·December 5, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications and that non-pharmacological interventions and informed consent were implemented prior to initiation of an antipsychotic medication for one of five residents reviewed for unnecessary medications (Resident 74).Findings included: A review of the facility policy titled Psychotropic Medication Use, last reviewed by the facility on November 6, 2025, revealed it is the facility's policy that residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and representative and includes determining adequate indications for use, establishing appropriate dose and duration, and determining appropriateness of gradual dose reduction. Circumstances that warrant an evaluation of the resident's underlying medical condition and medications include admission or readmission, a new or worsening change in condition, an irregularity identified during the drug regimen review, or a new medication ordered as an emergency measure. Further review of the policy revealed that psychotropic medication may be considered appropriate when a resident's behavioral symptoms present a danger to the resident or others, if the resident is exhibiting indications of distress, and if a gradual dose reduction was attempted but clinical symptoms returned. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: non-pharmacological alternatives, the indications and rationale for the recommendation, the potential risks and benefits, and the resident's/representative's right to accept or decline the treatment. The policy identifies antipsychotic medications as psychotropic drugs. A review of the resident's clinical record revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that include depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time) and anxiety (a mental condition that causes a feeling of worry, nervousness, or unease). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 10, 2025, revealed that Resident 74 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 review of outside hospital records provided by the facility for Resident 74 revealed that both Buspar (medication for anxiety) and Zoloft (medication for depression) were on their prior-to-admission medication list in their history and physical on admission. The discharge summary noted risperidone (an antipsychotic medication) was a new medication that was started. A Page 1 of 9 395872 395872 12/05/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clinical record review for Resident 74 revealed a physician's order dated May 6, 2025, for risperidone 0.25 mg one time a day for unspecified dementia, unspecified severity, with agitation. A clinical record review of a physician's progress note dated May 9, 2025, noted that Resident 74 had early dementia with agitation noted at the hospital and that they were currently on Risperdal (brand name for risperidone, an antipsychotic), and they would consult psychiatry and consider gradual dose reduction (GDR). A clinical record review of a psychiatric consultation note from the Certified Registered Nurse Practitioner (CRNP) dated May 12, 2025, revealed Resident 74 was evaluated for anxiety and lifestyle change with a history of neurocognitive disorder (a category of mental health conditions characterized by a decline in cognitive abilities such as memory, language, and problem-solving), anxiety, and depression, and it was noted to continue risperidone 0.25 mg daily for agitation and restlessness and to follow up next week and see if it is appropriate for a GDR. A review of a May 2025 Consultant Pharmacist Medication Regimen Review dated May 18, 2025, revealed the consultant pharmacist indicated that residents admitted on an antipsychotic medication must be evaluated for a dose reduction within fourteen (14) days of admission and that the resident was admitted with Risperdal 0.25 mg at bedtime for restlessness and agitation. The physician and psychiatric CRNP responded by marking that they disagreed, noting a rationale of recommending continuing the medication, as the benefits of the medication outweigh the risks of reduction due to the high incidence of agitation and restlessness. A clinical record review of a physician's progress note dated May 19, 2025, revealed that Resident 74 had been anxious and scared and wanted to go home, and that the resident was on Buspar 5 mg twice a day, and they would increase it to three times a day. The physician noted a conversation with the psychiatric consultant CRNP and a discussion that behavior management would be the most important thing to be done for the resident and that the resident needed more time to acclimate to the surroundings. Further review of the progress note revealed that psychiatry was to consider GDR but was held due to the resident's recent anxiety. A clinical record review of a psychiatric consultation note from the CRNP dated May 19, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and neurocognitive decline. It was noted that the family had complaints of resident anxiety, and the resident was on Buspar, and it was decided to increase it to 5 mg three times a day for anxiety. It was noted that the CRNP recommended GDR of risperidone and that they would address the GDR of risperidone with family and see if they are comfortable with it on the next visit. A clinical record review of a progress note from the Director of Nursing (DON) dated June 5, 2025, at 1:25 PM revealed that a recommendation from pharmacy was received for review of a dose reduction of Risperdal within fourteen (14) days of admission, and that the recommendation was reviewed by the psychiatric CRNP, who felt the benefits outweighed the risks of reduction due to the high incidence of agitation and delusions. It was noted that recommendations were also reviewed by the physician, and they agreed to continue medication as currently ordered. A review of a June 2025 Consultant Pharmacist Medication Regimen Review dated June 21, 2025, revealed the consultant pharmacist indicated that Resident 74 was receiving the antipsychotic agent Risperdal and restlessness and agitation were not allowable diagnoses to support its use. The physician and psychiatric CRNP then responded with a medical code, F03.811, as the diagnosis, which correlated to unspecified dementia, unspecified severity with agitation, and it was added to the resident's medical diagnosis as of July 14, 2025, in the clinical record. A clinical record review of a psychiatric consultation note from the CRNP dated July 14, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and dementia, and that the resident was noted to be stable and denied much anxiety and to continue risperidone for sleep, anxiety, and dementia. A clinical record review of a psychiatric consultation note from the CRNP 395872 Page 2 of 9 395872 12/05/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated August 4, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and dementia, and there was a discussion with the resident's physician, and the psychiatric CRNP was recommending discontinuing risperidone for GDR. A clinical record review of a psychiatric consultation note from the CRNP dated September 29, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and dementia and noted they denied needing medications and felt their mood was stable, and it was recommended to continue reminders, redirection, and reorientation. A plan for medication was to continue sertraline (a generic medication for Zoloft, an antidepressant) for depression, Buspar for anxiety, and melatonin for sleep. There was no mention in the psychiatric CRNP note regarding Resident 74 still taking risperidone 0.25 mg daily. A clinical record review of a psychiatric consultation note from the CRNP dated October 27, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and dementia and noted they denied needing medications and felt their mood was stable, and it was recommended to continue reminders, redirection, and reorientation. A plan for medication was to continue sertraline for depression, Buspar for anxiety, and melatonin for sleep. There was no mention in the psychiatric CRNP note regarding Resident 74 still taking risperidone 0.25 mg daily. A review of the clinical record from admission to time of survey revealed no documented episodes of agitation. The facility was unable to provide evidence of informed consent for the psychotropic medication risperidone, and it was not available in the clinical record for review. During an interview with the DON on December 5, 2025, at 9:30 AM, it was confirmed the facility failed to ensure that Resident 74 was free from unnecessary use of a psychotropic medication, resulting in the resident receiving an antipsychotic medication without documented evidence that it was required to treat a specific medical symptom and without evidence of informed consent or attempted non-drug interventions as required by regulation. 28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.2(d)(3) Medical director.28 Pa. Code 211.12(d)(3) Nursing services.28 Pa. Code 211.10(c) Resident care policies. 395872 Page 3 of 9 395872 12/05/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0641 Ensure each resident receives an accurate assessment. 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 Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 25 sampled (Residents 8 and 88).Findings included: A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain) and anxiety. A physician order dated November 9, 2025, noted an order for Ativan (an antianxiety medication) 0.5 mg by mouth every 6 hours as needed for anxiety. A review of Resident 8's Quarterly MDS assessment dated [DATE], Section N0415 indicated the resident did not receive antianxiety medications during the 7-day look-back period. A review of Resident 8's November 2025 Medication Administration Record (MAR) revealed the resident received Ativan 0.5 mg on November 13, 2025, at 8:15 PM, which was during the 7-day look-back period. An interview with the RNAC (registered nurse assessment coordinator) on December 3, 2025, at 10:00AM, confirmed Resident 8 did receive an antianxiety medication during the 7-day look-back period and the MDS was not accurate. A review of Resident 88's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and hypertension (blood pressure that is higher than normal). A clinical record review for Resident 88 revealed a physician's order dated August 13, 2025, for Warfarin (a blood-thinning medication also known as an anticoagulant) 6 mg by mouth daily on Mondays, Tuesdays, Wednesdays, Thursdays, Saturdays, and Sundays, and an order for 3 mg by mouth daily on Fridays. A review of Resident 88's admission MDS assessment dated [DATE], Section N0415 indicated the resident did not receive anticoagulant medications during the 7-day look-back period. A review of Resident 88's August 2025 MAR revealed the resident received Warfarin 3 mg and Warfarin 6 mg from August 13, 2025, to August 20, 2025, which was during the 7-day look-back period. An interview with the RNAC on December 3, 2025, at 10:00AM, confirmed Resident 88 did receive an anticoagulant medication during the 7-day look-back period and the MDS was not accurate. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Residents Affected - Few 395872 Page 4 of 9 395872 12/05/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide person-centered care by failing to follow physician's orders for the consistent application of a prescribed therapeutic measure, compression stockings, for one resident of 25 sampled (Resident 88).Findings include: A review of Resident 88's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should) and hypertension (blood pressure that is higher than normal). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 19, 2025, revealed that Resident 88 had moderately impaired cognition with a BIMS score of 12 (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 indicates cognition is moderately impaired). A review of Resident 88's clinical record revealed a physician's order dated September 30, 2025, for extra-large knee high TED hose (Thrombo-Embolus deterrent compression stockings, or anti-embolism stockings, which are specially designed to help reduce the risk of developing blood clots in your lower leg after surgery) to be on in the morning at 6:00 AM and removed in the evening at 9:00 PM, and may apply ace wraps if unavailable. During a resident interview on December 3, 2025, at 11:00 AM, Resident 88 reported that staff did not assist them with applying their TED stockings that day, despite a physician's order requiring their use. Observations made on December 3, 2025, at 11:00 AM revealed that Resident 88 was not wearing their TED stockings as ordered, which was confirmed by Employee 5, licensed practical nurse. A review of Resident 88's December 2025 Treatment Administration Record revealed that staff documented the TED stockings were applied at 9:48 AM on December 3, 2025. This documentation was inconsistent with the resident's statements and observed findings. During an interview with the Director of Nursing on December 3, 2025, at 2:30 PM, it was confirmed that staff did not follow the physician's orders regarding the application of Resident 88's TED stockings.28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services Residents Affected - Few 395872 Page 5 of 9 395872 12/05/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0699 Provide care or services that was trauma informed and/or culturally competent. 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 interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to provide trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 25 residents reviewed (Resident 10).Findings include:A review of the clinical record revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder (PTSD, a mental health condition that can develop after someone experiences or witnesses a traumatic event such as violence, accidents, natural disasters, war, or abuse), depression, and anxiety. The resident's current care plan, in effect at the time of review beginning December 3, 2025, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and did not identify resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.Interview with the Nursing Home Administrator on December 5, 2025, at 11:00 AM, confirmed that the facility had not identified symptoms or triggers related to Resident 10's PTSD diagnosis.The facility was unable to demonstrate that the facility provided trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.28 Pa Code 211.12 (d)(3)(5) Nursing services Residents Affected - Few 395872 Page 6 of 9 395872 12/05/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

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, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of four medication carts observed (A-Hall medication cart). Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility November 6, 2025, indicated that multi-use vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. An observation of the A-Hall medication cart on December 4, 2025, at 9:10 AM, in the presence of Employee 4, licensed practical nurse (LPN), of medication stored in the medication cart, revealed a multi-dose pen of Aspart Insulin (a rapid-acting insulin medication used to lower blood sugar) opened on August 28, 2025. Further observations revealed a Lispro multi-dose pen (a rapid-acting insulin medication used to lower blood sugar) that had been opened and available for use but not dated when initially opened. An interview with Employee 4 at the time of the observation on December 4, 2025, at 9:10 AM, confirmed the Aspart insulin pen was beyond the manufacturer's recommended 28-day discard date, and the Lispro insulin pen had been opened and not dated, and the medications should have been removed from the medication cart and discarded. An interview with the Nursing Home Administrator on December 4, 2025, at 11:00 AM, confirmed the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services28 Pa. Code 211.12(c)(d)(1)(5) Nursing services 28 Pa Code 211.10 (a)(c) Resident care policies. 395872 Page 7 of 9 395872 12/05/2025 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 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 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 food and nutrition services department.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).Review of the food and nutrition services department's Hand Washing Policy last reviewed November 6, 2025, indicated that staff will wash hands frequently as needed during the day. The procedure for when to wash hands noted that hands are to be washed after handling soiled equipment or utensils. Observation on December 3, 2025, at 8:45 AM during the initial tour of the food and nutrition services department conducted with the registered dietitian and foodservice director (FSD) revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:Employee 3 (dietary aide) was working both the dirty and clean sides of the dishwashing machine. Employee 3 (dietary aide) was observed placing dirty dishes through the dishwashing machine and then removing the clean dishes from the dishwashing machine without washing hands to prevent cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect) of the clean dishes. Observation revealed the facility had a low temperature dishwashing machine (requires a wash temperature of 120 degrees Fahrenheit and requires a chlorine based chemical sanitizer with a sanitization level of 50 parts per million). However, chlorine testing strips to test the level of chemical sanitizer were not available. An Interview with the FSD at the time of the observation confirmed that chlorine testing strips were required to ensure the sanitizer was maintained at 50 PPM (parts per million). Observation of the clean dish storage area revealed there were six thermal beverage mugs, two thermal soup bowls, and two plastic cold beverage glasses identified as clean, which had visible dark stains and food debris on their interior surfaces, indicating inadequate cleaning practices and a failure to meet sanitation standards for food service equipment.The floor area beneath the tray line and steamtable in the kitchen had a build-up of dirt and debris, 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.There were three covered bowls of powdered creamer on a shelf in the dry storage room which were not dated. Interview with the food service director (FSD) on December 3, 2025, at 9:30 AM confirmed the food and nutrition services department was to be maintained in a sanitary manner, food items were to be dated, and manufacturer guidelines and facility policy and procedures were to be followed to ensure quality and food safety to prevent opportunities for foodborne illness and to comply with federal food safety regulations. 28 Pa Code 201.18 (e) (2.1) Management.28 Pa Code 211.6(f) Dietary services.28 Pa Code 211.10 (a)(d) Resident care policies. 395872 Page 8 of 9 395872 12/05/2025 Gardens at Millville, The 48 Haven Lane Millville, PA 17846

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records and select facility policy, and staff interviews, it was determined the facility failed to implement procedures for smoking safety and safety of smoking areas, as evidenced by one out of the 25 residents (Resident 22).Findings include:A review of the facility policy titled Tobacco Policy, last reviewed by the facility on November 6, 2025, revealed it is the policy of the facility to promote safety as well as a healthful work and living space. The policy indicates that all resident smoking will be under supervision, during scheduled smoking times, and in the designated smoking area. Also, the policy indicates that smoking may be suspended temporarily for inclement weather such as temperatures below freezing and high winds.A clinical record review revealed Resident 22 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 9, 2025, revealed that Resident 22 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 to 12 indicates cognition is moderately impaired).A review of Resident 22's care plan revealed that he is at risk for injury related to smoking initiated on June 2, 2022. Intervention implemented to mitigate Resident 22's risk for injury related to smoking include monitoring resident while smoking, monitoring smoking in designated areas, and utilizing a protective apron while the resident is smoking.A review of the Smoking and Electronic Cigarette Evaluation form dated January 28, 2025, revealed the resident must be supervised by staff, volunteers, or family member at all times when smoking tobacco products or using electronic cigarettes.An observation on December 4, 2025, at 9:28 AM revealed Resident 22 was in his wheelchair smoking in the outside designated smoking area. Employee 1, Activities Assistant (AA), was observed supervising Resident 22. Resident 22 was sitting in his wheel chair smoking a lit cigarette. Underneath and around his wheel chair were multiple piles of dried leaves creating a fire hazard.During an interview on December 4, 2025, at 9:28 AM Employee 1, AA, indicated that maintenance is responsible for ensuring the area is free of dry leaves. She indicate that she did not notify the maintenance department about the leaves prior to lighting Resident 22's cigarette.During an interview on December 4, 2025, at 9:32 AM Employee 2, Director of Maintenance, confirmed that she ensures the resident smoking area is free of dry leaves or other combustible material. She explained that she was not informed that leaves had blown into the area. Employee 2, Director of Maintenance confirmed that Resident 22 should not be smoking over a pile of dried leaves and removed the leaves with broom.During an interview on December 5, 2025, at 10:30 AM the findings were review with the Nursing Home Administrator (NHA). The NHA confirmed the smoking area should be free of combustible materials, like piles of dried leaves, to ensure resident safety. The facility failed to implement procedures to ensure residents were able to safely smoke.28 Pa. Code 201.18 (b)(1)(e)(1) Management.28 Pa. Code 209.3 (a) Smoking.28 Pa. Code 211.10 (d) Resident care policies. Residents Affected - Few 395872 Page 9 of 9