Inspection·June 6, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select resident incident/accident reports and information submitted by the facility and staff interview, it was determined that the facility failed to provide safe and adequate staff supervision with activities of daily living to a resident, with identified positioning difficulties, resulting in an avoidable fall during which the resident sustained multiple traumatic injuries for one resident out of seven sampled (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with a diagnosis of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated February 20, 2022, revealed that the resident required extensive assistance of two staff for bed mobility, transferring, and dressing, and required supervision of one staff member when moving about on the nursing unit. The clinical record revealed that the resident was receiving occupational therapy services beginning March 2, 2023. A review of this occupational therapy evaluation and progress notes revealed that the resident had poor sitting balance. It was noted that the resident had poor positioning issues when sitting, such as sliding forward from her wheelchair seat, and not having proper head support. The resident was identified to have limited trunk flexion (returns the trunk to the anatomical position from trunk extension or produces a forward movement of the spine). A review of an occupational therapy Discharge summary dated [DATE], revealed that the resident was discharged from occupational therapy services on March 17, 2023, and at the time of discharge, the resident could tolerate sitting in her wheelchair with positioning devices in place. A nursing progress note dated May 15, 2023, at 6:39 AM, but written and entered into the clinical record on May 18, 2023, at 7:52 AM, revealed that nursing found the resident on the floor of the resident's room, lying on her stomach with the right side of her face on the floor and her right arm underneath her. It was noted that the resident was unresponsive for 10 to 15 seconds. The resident's right cheek and right eye were swollen, and she complained of right arm pain. According to the late entry nurse's note, Employee 1, a nurse aide, was attempting to dress and then transfer the resident from bed, without the assistance of a second staff member. Employee 1 reported that the aide sat the resident on the side of the resident's bed to pull the resident's shirt down and to place a lift pad under her. Employee 1 indicated that Resident 1 fell forward and the employee was unable to stop the resident's fall. The resident fell to the floor, hitting the right side of her face. The physician was notified, and an order was obtained to transfer the resident to the hospital. A review of a corresponding incident report dated May 15, 2023, at 6:30 AM revealed that the resident was found on the floor in her room on her stomach. The resident was noted to lose consciousness after the fall for 10 to 15 seconds. Resident 1 had swelling to her right cheek and right eye and complained of pain in her right arm. The report noted that resident was supposed to be an assist of two staff member with a full mechanical lift for all transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 2 of 6 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 396148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delaware Valley Skilled Nursing & Rehabilitation C 111 Rivers Edge Drive Matamoras, PA 18336 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 Residents Affected - Few Employee 1's witness statement indicated that the employee was trying to get the resident up (from bed). The employee stated that she sat the resident on the side of the bed to pull her shirt down and the resident started to fall forward. Employee 1 stated that she tried to catch her, but it was too late. The facility's investigation revealed that there was a sit to stand lift present in the resident's room when Resident 1 fell. However, at the time of the incident, the resident was to be transferred with the use of full mechanical lift, as a sit to stand lift was determined to be unsafe for the resident. The facility conducted a telephone interview on May 15, 2023, with Employee 1 during which the employee stated that she did not bring the sit to stand lift into the resident's room at the time of the resident's fall, but that it was already in the resident's room located near the closet. However, when the facility informed Employee 1 that they were going to review the video footage to validate her story, Employee 1 admitted to bringing the sit to stand lift into the room intending to use the lift to transfer the resident out of bed. Employee 1 stated that she just sat the resident on the side of the bed to pull her shirt down and the resident fell forward. An undated witness statement from Employee 2, a nurse aide, revealed that Employee 3, LPN (license practical nurse) approached Employee 2 at 5:15 AM (on May 15, 2023) for help with Resident 1 since the resident is hard to manage. At that time Employee 2 and Employee 3 provided bowel and bladder toileting, washed the resident, completely dressed the resident, and changed her sheets. Employee 2 indicated that the resident's shirt, at that time, was all the way down. Employee 2 stated that there were no lift machines in the resident's room at that time. Employee 3's witness undated statement indicated that the employee assisted Employee 2 with providing care to the resident on the day of the resident's fall. When she entered the room later at 6:15 AM she saw the resident face down on the floor. The employee further indicated she did see Employee 1 go to the 400 hall of the nursing unit to get the sit to stand lift before the fall had occurred. A review of the resident's hospital records dated May 15, 2023, revealed that the resident was being moved and was dropped and landed flat and hit her head on the floor with a loss on consciousness for 15 seconds. The resident sustained a right orbital floor fracture (trauma to the orbital rim pushes the bones back, causing the bones of the eye socket floor buckle to downward), multiple maxillary sinus fractures (a break to the area under the eye next to the nose usually caused by blunt force trauma), right middle finger proximal phalanx fracture (a break, of a small bone in the finger), right ulna fracture (a break in the forearm), and right femoral fracture (a break in the thigh bone). The resident also had multicompartment intracranial hemorrhage (brain bleed) including bilateral subarachnoid (a bleed in the area that surrounds the brain), intraparenchymal (bleeding in the functional part of the brain) and subdural (bleeding in the area between the brain and the skull) with intraventricular extension (bleeding extended into the ventricles{ a communicating network of cavities within the brain}). An interview with Employee 4, Director of Rehab, on June 6, 2023, at approximately 11:00 AM reveled that the resident had been re-evaluated in October 2022 for the use of a full mechanical lift as the resident was no longer safe using a sit to stand lift. Employee 4 stated that the resident was not safe to sit upright alone and had poor sitting posture. Employee 4 stated that the resident needed assistive interventions to be seated in a reclined wheelchair to sit safely. Employee 4 confirmed that the resident would not need to sit on the side of the bed for a transfer using the full (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 3 of 6 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 396148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delaware Valley Skilled Nursing & Rehabilitation C 111 Rivers Edge Drive Matamoras, PA 18336 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 Residents Affected - Few mechanical lift, nor would the resident need to sit on the side of the bed for staff to pull her shirt down. While dressing the resident, the resident's shirt could have been pulled down while the resident was still lying in the bed. According to information dated May 17, 2023, submitted by the facility, Employee 1 maintained that she was only providing assistance with dressing and she did not intend to use the device (sit to stand lift). However, Resident 1 required the assistance of two staff with dressing and had poor upper body trunk control. Employee 1 was attempting to dress, and preparing to transfer the resident out of bed, without the assistance of another staff member. Employee 1 was terminated on May 16, 2023. An interview with the Nursing Home Administrator on June 6, 2023, at approximately 2:15 PM confirmed that Employee 1 failed to provide care, consistent with Resident 1's assessed needs and planned care for dressing and transfers, resulting in Resident 1's fall from bed and multiple traumatic injuries. 28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services 28 Pa. Code 211.11 (d) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 4 of 6 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 396148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delaware Valley Skilled Nursing & Rehabilitation C 111 Rivers Edge Drive Matamoras, PA 18336 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, the facility's diet manual and select facility investigative reports, and staff interviews, it was determined that the facility failed to ensure that a resident identified with swallowing difficulties was consistently served food in a form to meet the resident's individual needs for one resident out of seven sampled (Resident 3). Findings Include: Review of the clinical record revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by progressive or persistent loss of cognitive functioning). Resident 3 had a current physician order for a regular Puree 3 texture diet with nectar thickened consistency liquids (liquids thickened to the consistency similar to apricot nectar) initially dated February 28, 2023 (pureed diet is a type of diet that consists of foods with a smooth pudding-like consistency). Resident 3's quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 9, 2023, indicated that the resident was provided a mechanically altered diet (a diet that required a change in texture of food) daily. A review of the facility Diet Manual dated March 2021, revealed that a pureed consistency diet should be reserved for individuals with severe choking or swallowing problems. Foods are modified to a blended consistency to require little or no chewing for digestion. Procedures for thickened liquids noted that the liquids should be thickened to the consistency as ordered. A review of a facility incident report dated March 14, 2023, at 5:30 p.m. indicated that Employee 5, a nurse aide, served Resident 3 a bowl of soup that was not mechanically altered (neither pureed nor thickened to nectar consistency). Resident 3 began consuming the soup and began to cough and vomit. The report noted that Employee 5 did not read Resident 3's diet tray ticket (specifying the resident's prescribed diet and food/beverages to be served at that meal) before serving the resident soup. The type of soup on which the resident choked was not noted on the incident report. At the time of the survey ending June 6, 2023, the facility was unable to identify what type of soup the resident had been served, only that the soup was not pureed nor thickened to the nectar consistency the resident required. A review of facility planned menu for the evening meal on March 14, 2023, revealed that soup was not on the planned menu for that evening meal. A nursing progress note dated March 14, 2023, at 11:20 p.m., indicated that Resident 3 ate a few spoons of soup intended for those on regular consistency diets. Resident 3 had some vomiting of a foamy like texture. The resident had some complaints of chest pain or feeling like something was sitting on chest. The physician notified and requested that the resident be sent to the emergency department (ED) for evaluation of chest pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 5 of 6 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 396148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delaware Valley Skilled Nursing & Rehabilitation C 111 Rivers Edge Drive Matamoras, PA 18336 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Hospital documentation dated March 15, 2023, indicated that Resident 3 had significant esophagitis (inflammation of the esophagus) and erythema (redness of the skin or mucus membranes). A nursing progress note dated March 16, 2023, at 8:36 p.m., noted that Resident 3 returned from hospital and was prescribed amoxicillin clavulanate 875-125 mg 1 tab two times daily for aspiration pneumonia x 6 doses and pantoprazole 40 mg 1 tab two times daily for hiatal hernia with mild inflammation. Interviews with the director of nursing (DON) and nursing home administrator (NHA) on June 6, 2023, at approximately 11:00 a.m. revealed that the facility had soup available in the dining room at the evening meal on March 14, 2023. Employee 5 reportedly grabbed a serving of regular consistency soup that was not thickened or pureed and served it to the resident. The DON and NHA confirmed that the facility failed to serve food to Resident 3 to meet the resident's individual needs and current prescribed pureed diet with nectar thick liquids resulting in a choking episode. 28 Pa. Code 211.6 (c)(d) Dietary services 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 6 of 6