Inspection·February 20, 2026

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 record review and Staff interview, the facility failed to develop and implement a baseline care plan for each resident that includes the minimum healthcare information to properly care for a resident for one out of 15 residents reviewed (Resident 45). Findings include:A review of facility policy Care/Service Plans, dated [DATE], indicates that each guest/resident will have an individualized Care/Service plan developed. Care/Service Plans will include guest/resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs.Review of Resident 45's PASRR Level I (Pennsylvania Preadmission Screening Resident Review, a screening tool to identify those with serious mental illness or intellectual and developmental disabilities to ensure they receive appropriate care) completed [DATE] revealed that Resident 45 had a positive screen for a PASRR Level II evaluation (an evaluation that ensures individuals are not inappropriately placed in nursing homes and that their psychological, psychiatric, and functional needs are considered in care planning.)Review of Resident 45's medical record reveals that they were admitted to the facility on [DATE] with a diagnosis of cerebral aneurism (a building or weak blood vessel in the brain that can cause rupture or bleeding), major depressive disorder (a mental health condition characterized by persistent feelings of sadness and loss of interest in activities), atrial fibrillation (an irregular heart rhythm) and diabetes mellitus type 2 (a disorder of the metabolism characterized by high blood sugar, which can lead to health complications).Review of Resident 45's initial psychology consultation dated February 3, 2026 reveals resident stated I almost died in a fire which occurred 6 years ago. She said no one died or was seriously injured except for her. She said there are times she thinks about it and may get that hyperalert feeling.Review of Resident 45's Initial Comprehensive Psychiatric Exam dated February 4, 2026 revealed my life changed after the fire in the condo, it was right before COVID-19 and then I came to [independent living], I don't think I was ready, I think I came too soon. But I could not go back to that condo.Review of Resident 45's Holistic Assessment Cognitive Patterns, Mood, and Expressions dated February 8, 2026 revealed a positive history of anxiety, depression and suicidal ideations, with past inpatient psychiatric hospital stays. The assessment revealed the resident has a BIMS of 15 (Brief Interview of Mental Status is a standardized tool to screen for cognitive status. A score of 15 indicates normal thinking and memory). The assessment further revealed a positive screen for PASSAR Level 2 requiring Rehabilitative services, Medical or social supports and a positive screen for PTSD (Post Traumatic Stress Disorder, a mental health condition caused by an extremely stressful or terrifying event) due to a house fire in 2020. In response to the question In the past month, have these experiences caused you ongoing distress, the resident responded affirmatively.Review of Resident 45's care plan dated February 10, 2026 revealed no history of post-traumatic stress, positive PASRR Level 2 screen, or past history of suicidal ideations under the Cognitive Patterns, Mood, and Expressions section. There is a note to medicate as ordered by the Provider, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 396123 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 396123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Care at Maris Grove 500 Maris Grove Way Glen Mills, PA 19342 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)