Inspection·September 8, 2023

F 0658 1. Level of Harm - Minimal harm or potential for actual harm A major mood episode (either major depression or mania) that lasts for an uninterrupted period of time 2. Residents Affected - Few Delusions or hallucinations for two or more consecutive weeks without mood symptoms sometime during the life of the illness 3. Mood symptoms are present for the majority of the illness 4. The symptoms are not caused by substance abuse. A review of the Resident 35's clinical record revealed that the resident was admitted to the facility on [DATE], with one psychiatric/mood disorders: major depressive disorder. A review of consult from the facility's Psychological Service provider dated March 6, 2023, revealed that the resident had a psychiatric history of Major depressive disorder, and dementia with behavioral disturbance. Further review of consult from the facility's Psychological Service provider dated March 6, 2023, revealed that the resident now had a new diagnosis of schizoaffective disorder. A review of Resident 3's resident's medical diagnosis list revealed a diagnosis of Schizoaffective disorder was added on June 2, 2023. A review of Resident 3's comprehensive plan of care from the time of the resident's admission through the survey ending September 8, 2023, revealed that the diagnosis of Schizoaffective Disorder was not addressed on the resident's plan of care. There was no documented evidence in the resident's clinical record to demonstrate that a clinical practitioner had diagnosed the resident with schizoaffective disorder with documented supporting clinical findings in the resident's clinical record from the time of the resident's admission to the facility on May 18, 2022, through the current survey which ended on September 8, 2023 Interview with the Director of Nursing on July 21, 2023, at approximately 2:00 PM, confirmed the facility did not have documented evidence of a practitioner diagnosing the resident with schizoaffective disorder according to professional standards. 28 Pa. Code 211.2 (d)(3) Physician services 28 Pa. Code 211.5 (f)(iv)(v)Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 2 of 19 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 09/08/2023 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 0660 Plan the resident's discharge to meet the resident's goals and needs. 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 interviews it was determined that the facility failed to develop and implement an individualized discharge plan for one of 15 residents reviewed (Resident 52) to reflect the resident's discharge goals. Residents Affected - Few Findings Include: Clinical record review revealed that Resident 52 was admitted to the facility on [DATE], with diagnoses to include kidney disease. Review of an admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated August 13, 2023, indicated that the resident was mildly cognitively impaired with a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 11 (a score of 7-12 indicated that the resident was mildly cognitively impaired). A review of the resident's care plan initially dated August 11, 2023, and reviewed during the survey ending September 8, 2023, revealed no documented evidence that an individualized discharge plan was developed, and revised, as needed to reflect the resident's current desire for discharge or long-term placement at the facility. Review of social service progress notes beginning August 10, 2023, revealed that the resident told social services staff that she was interested in planning a discharge to home. As of review on September 8, 2023, there was no further documentation regarding the resident's interest for a potential discharge to home. During an interview with the Nursing Home Administrator on September 7, 2023, at 12:00 PM confirmed that there was no documented evidence of a current discharge goal and plan for this resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 3 of 19 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 09/08/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, observations and staff and resident interviews it was determined that the facility failed to consistently monitor the resident's skin integrity related to the use of a therapeutic device to prevent pressure sore development for one out of 10 residents sampled with pressure injuries (Resident 27). Residents Affected - Some Findings included: Review of Resident 27's clinical record readmission to the facility on May 24, 2023, with diagnoses that included a recent intracapsular fracture to the right femur [the ball on the top of the femur has broken off at its junction with the neck of the upper thigh bone, within the hip joint], and fracture of the orbital floor [occurs when an injury pushes the eye socket backward that can also affect the eye's muscles and nerves] right side, dementia without behavior disturbance, and muscle wasting with atrophy [is the loss of muscle leading to its shrinking and weakening]. A review of Resident 27's plan of care dated initially September 13, 2021, revealed resident had the potential for impaired skin integrity related to a history of pressure ulcers, incontinence, and history of cellulitis with a goal for the resident to not experience any pressure ulcers or other skin issues with planned interventions to apply treatments as per physician orders, provide routine position change through weight shifting, transfer to bed/toilet, and to stand at intervals with assist. A review of a physical therapy (PT) evaluation and plan of treatment dated May 25, 2023, revealed that the resident declined PT services due to the severity of her pain. PT recommended a soft right splint, pillows for proper positioning for comfort, and heel protectors. A review of a significant change Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed that the resident had mild cognitive impairment, required extensive assistance of two plus persons physical assist for toileting, dressing, bed mobility, and totally dependent for transfers with two plus persons assistance and not steady during surface-to-surface transfers. A new pressure incident investigation report, completed by Employee 2, a licensed practical nurse (LPN), dated June 30, 2023, at 10:59 PM, revealed that the resident had complaints of pain to her right hand. The resident's right fingers were red and edematous (swollen). Nursing removed ace wrap and splint to the resident's right arm and discovered 3 new open areas. The first wound was on the back of her right hand and measured a 1.5-inch length x 2.0 inches wide x 0.5 cm deep circular wound with odor, white slough, and whitish green drainage. Second wound was 3.0 inch x 2.0 inch x 0.5 cm deep at the top x 1.0 cm deep at the bottom along the thumb of the right palm hand with odor, greenish drainage, surrounding skin is black in color. The third wound, along pinky of the right hand 2.0-inch red area, dry in nature, no drainage noted. The physician and responsible party were notified. The MD ordered Keflex [is used to treat infections caused by bacteria, including upper respiratory infections, ear infections, skin infections, urinary tract infections and bone infections] three times per day for 7-days, cleaned with wound wash and applied sliver alginate with gauze [collects excess fluids leaking out of a wound and can also help keep the wound from getting infected and is best (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 4 of 19 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 09/08/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some intended for moderate to highly exuding wounds], and abd pads and wrapped with cling wrap. Dressing dated, timed, and signed. A Pain Assessment in Advanced Dementia [PAINAD is used to assess pain in older adults who have dementia or other cognitive impairment and are unable to reliably communicate their pain] completed following the identification of the skin breakdown upon removal of the splint, revealed that the resident exhibited an occasional moan or groan, low level of speech with negative quality, had facial grimacing, was rigid with fists clenched and knees pulled up and pulling or pushing away. The facility was unable to provide evidence of a physician order for the use for the splint to the resident's right hand. Additionally, there was no documented evidence that a wearing schedule was established for staff to apply and remove the splint to render care such as cleansing and monitoring the skin integrity under the splint to prevent skin breakdown, infection, and pain. During an interview with the Director of Nursing (DON) on September 8, 2023, at 12:35 PM, confirmed that the facility was unable to provide evidence of a wearing schedule for the right-hand splint and that preventative measures to deter skin breakdown and infection were being consistently performed to monitor the skin integrity under and surrounding the splint. Further review of a new pressure incident investigation report that was completed by Employee 3, a LPN, and dated July 3, 2023, at 9:15 AM, revealed that during morning care that an area of concern was noted. A Left hip discoloration with a purple center and surrounded by a reddened area. The resident was unable to give a description. Identified predisposing physiological factors included confusion, impaired memory, and incontinence. It was noted that Resident 27 had an air mattress was in place and that the resident recently sustained a right hip fracture and tended to lean on her left side while in bed due to fracture. Immediate action was to notify the MD and responsible party and every one hour turn and reposition while in bed implemented. A review of Resident 27's wound evaluation flow sheet that was completed by the DON on July 3, 2023, no time noted, revealed that the resident developed a facility acquired area to her left hip that was assessed as a DTI [a deep tissue injury is an injury to a underlying tissue below the skin's surface that results from prolonged pressure in an area of the body that is similar to a pressure sore, a deep tissue injury restricts blood flow in the tissue causing the tissue to die] {noted on the wound evaluation flow sheet as a stage 3 pressure ulcer} that measured 4.0 cm in length by 4.0 cm in width by 0.0 cm in depth, red blanchable {when pressed on the skin the area the redness resolves and then returns and indicates blood flow} with red 2.0 cm in length by 2.0 cm in width by 0.0 cm in depth and non-blanchable {when pressed the skin remains red and indicates that there is little or no blood flow going to that area}, no exudate {a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation}, no drainage, no odor, with 100% epithelial tissue. Current treatment was skin prep and turning and repositioning every one hour and nutritional supplements. A review of Resident 27's task survey documentation report for June 2023 (prior to the identification of new facility pressure ulcer) revealed that nursing were to complete turning and repositioning every shift. The report revealed no documented evidence that the task was being performed on 70 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 5 of 19 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 09/08/2023 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 0686 occasions out of 90 scheduled tasks for staff to provide turning and repositioning. Level of Harm - Minimal harm or potential for actual harm The survey documentation report for July 2023 revealed that the planned preventative measures to maintain the resident's skin integrity, for skin observations every shift and to turn and reposition each shift, was not completed during all shifts on July 1, 2023, and July 2, 2023. The resident subsequently developed a DTI to Resident 27's that was found during day shift July 3, 2023. Residents Affected - Some The resident's care plan was not revised with individualized interventions to prevent the development of skin impairments after a significant change in condition and movement occurred after the resident's hip fracture. During an interview with the DON on September 8, 2023, at 12:40 PM, confirmed that the facility was unable to provide documented evidence that planned preventative measures to deter skin breakdown, to include consistent timely turning and repositioning and skin observations each shift, were consistently performed for Resident 27. The DON confirmed that the resident's care plan for skin integrity was not revised after the resident's hip fracture. 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 6 of 19 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 09/08/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy and personnel records and staff interviews it was determined that the facility failed to assure the consistent implementation of safety measures designed to prevent elopement for one resident out of four sampled residents (Resident 10). Findings include: Review of a facility policy entitled Wandering and Elopements that was last reviewed by the facility June 2023, indicated that the facility will identify residents who are at risk for unsafe wandering which includes leaving the premises or a safe area without authorization, knowledge, and supervision. If an employee observes a resident leaving, he/she should attempt to prevent the resident from leaving in a courteous manner. A review of Resident 10's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder [is a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder], cognitive communication deficit [may occur after a stroke, tumor, brain injury, progressive degenerative brain disorder, or other neurological damage, which may result in difficulty with thinking and how someone uses language], and major recurrent depressive disorder [is a mood disorder that causes a persistent feeling of sadness and loss of interest and affects how one feels, thinks and behaves and can lead to a variety of emotional and physical problems]. A review of a quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 18, 2023, revealed that the resident is moderately cognitively impaired with a BIMS score (brief interview for mental status -section of MDS that assesses cognition) of 08 (a score of 8-12 indicates moderately impaired cognition) and able to walk in the corridor on the unit with supervision and setup help only with use of a walker. Additionally, section E0900. Wandering - Presence & Frequency - has the resident wandered was coded that the behavior of this type occurred 1 to 3 days during the look back period prior to the assessment date. A review of Resident 10's plan of care that was initiated on August 5, 2023, identified that the resident was an elopement risk/wanderer and had auditory and visual hallucinations related to the disease process of dementia with and behavioral disturbance, and a history of attempts to leave facility unattended with impaired safety awareness. The goal was that the resident's safety will be maintained and that the resident would not leave the facility unattended. Planned interventions were to identify pattern of wandering such as wandering purposeful, aimless, or escapist, the resident looking for something, indicate that the need for more exercise, and intervene as appropriate related to Resident 10's attempt to climb out her window. Additional planned interventions to address wandering behaviors were to re-direct and re-orient the resident when experiencing auditory and visual hallucinations and a window alarm was placed on the right side of the wall window frame/ mid window area and the actual window {alarm would sound when the window was pushed upwards to open, check for function and placement at 7:00 AM and 7:00 PM every day and prn (as needed)}. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 7 of 19 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 09/08/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few A review of a facility investigation report dated September 6, 2023, at 9:30 AM, revealed that Resident 10 was standing in the café area with her rolling walker and some personal items. She walked up to the door and Employee 1, a laundry aid/housekeeping staff, was using the code pad to enter access code to enter the front area and Resident 10 told Employee 1 that she was waiting for her ride and Employee 1 allowed the resident to go through the door to the front lobby. The Nursing Home Administrator redirected Resident 10 from the front door lobby door with assistance of the Social Service Worker. The Social Service Worker brought the resident back into the nursing unit safely. Review of Employee 1's witness statement dated September 6, 2023, indicated that at roughly 10:00 AM this morning, I went to go to grab my personal sheet from the main desk printer to start my objective in the laundry room. When I approached the doors, I noticed that there was a resident coming in. I went to inform someone at the front desk that she was attempting to come in. After grabbing my sheet, I noticed that she was in the lobby but being assisted from the people that I attempted to inform. After I assumed she was being helped, so I left. A review of Employee 1's personnel file revealed no documented evidence that the employee was trained and educated on the facility's elopement policy and procedures in effort to prevent a wandering resident from entering an area without staff supervisor. Interview with the Nursing Home Administration (NHA) on September 7, 2023, at approximately 1:30 PM, indicated that Employee 1 should not have opened the key padded locked door that led to the facility's lobby area allowing an identified wandering resident to pass through the door to an unauthorized area for a wandering area. The NHA confirmed that there was no documented evidence that Employee 1 received training on the facility's elopement policy to protect wandering and exit seeking residents. CFR 483.25 (d)(1)(2) Accidents Continuing deficiency 6/6/23, 8/16/23 28 Pa. Code 201.20 (a)(1)(b)(d) Staff development FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 8 of 19 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 09/08/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 select facility policy and clinical records and staff interview, it was determined that the facility failed to administer pain medication as prescribed by the physician and attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 15 residents sampled (Resident 14). Residents Affected - Some Findings include: A review of the facility policy entitled Pain - Clinical Protocol, last reviewed June 2023 indicated that the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Additionally, it is noted staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Treatment and Management of pain includes that the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. A review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses of heart failure, dementia, and repeated falls. Review of an admission MDS assessment dated [DATE], revealed that the resident received PRN pain medications and did not receive non-medication intervention for pain in the last 5 days. The resident stated that he occasionally experienced pain or hurting in the last 5 days and rated this pain on a scale of 0-10 (zero being no pain and ten as the worst pain you can imagine), as a 1 according to the MDS. Review of Resident 14's initial care plan, dated August 25, 2023, revealed a focus of left elbow cellulitis with a desired outcome to show no signs or symptoms of infection and a planned intervention to evaluate pain. A physician order dated August 15, 2023, was noted for Acetaminophen 325 mg, give two tablets every 6 hours as needed for pain - mild (rated 1 - 5), an order dated August 18, 2023 for Tylenol extra strength 500 mg, give two tablets every 6 hours as needed for pain - moderate (rated 5-7), and an order dated August 25, 2023 for Tramadol HCL (opioid pain medication) 50 mg, give one tablet every 6 hours as needed for moderate pain (no pain rating noted with physician order). The resident had an order for both Tylenol ES 500 mg for moderate pain and the opioid pain medication, Tramadol for moderate pain. There was no delineation as to when the resident should receive prn Tylenol ES for moderate pain or Tramadol 50 mg for moderate pain noted on the MARs. Review of Resident 14's August 2023 Medication Administration Record (MAR) revealed that on August 17, 2023, the resident verbalized a pain level of 6 during the night shift, on August 18, 2023, the resident verbalized a pain level of 6 on the day shift and a pain level of 5 on the evening shift, on August 22, 2023, the resident verbalized a pain level of 6 on the day shift, on August 23, 2023, the resident verbalized a pain level of 4 on the day shift and a pain level of 2 on the evening shift, on August 28, 2023, the resident verbalized a pain level of 2 on the day shift and a pain level of 5 on the evening shift, and on August 29, 2023, the resident verbalized a pain level of 6 on the evening shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 9 of 19 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 09/08/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some There was no evidence that the staff attempted non-pharmacological and/or administration of as needed pain medication to alleviate his verbalizations of pain. Further review of Resident 14's August MAR revealed that on August 23, 2023, the resident received Tylenol extra strength for complaints of pain at a pain level of 8. On August 27, 29, and 31, 2023, the resident received Tramadol for complaints of a pain level of 8. The Tylenol ES was administered outside the physician paramaters of moderate pain rated 5-7 and Tramadol was administered for moderate pain, based on the same rating of 5-7, although resident's pain was rated at an 8. There was no evidence that the nursing staff attempted non-pharmacological interventions prior to the administration of as needed pain medication. Review of Resident 14's September 2023 MAR revealed that on September 2, 2023, the resident verbalized a pain level of 4 on the day shift, and on September 5, 2023, the resident complained of a pain level of 5 on the day shift. There was no evidence that the nursing staff attempted non-pharmacological and/or administration of as needed pain medication in response to the resident's verbalizations of pain. Further review of Resident 14's September MAR revealed that on September 3, 2023, the resident received Tylenol extra strength for complaints of a pain level of 4 (mild pain), and on September 6, 2023, the resident received Tramadol for complaints of a pain level of 8. Each of these administrations were not administered according to physician orders. Additionally, there was no evidence that the nursing staff attempted non-pharmacological interventions prior to the administration of as needed pain medication. Interview with the Nursing Home Administrator on September 8, 2023 at approximately 2:00 PM confirmed facility failed to provide effective pain management and administer pain medication as per physician order or attempt non-pharmacological interventions. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services 28 Pa. Code 211.5 (f) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 10 of 19 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 09/08/2023 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was revealed that the facility failed to timely notify the physician of abnormal lab results to prevent delays in treatment of one resident out of 15 sampled (Resident 14). Findings include: A review of clinical records revealed Resident 14 was admitted to the facility on [DATE], with diagnoses which included heart failure, dementia, and repeated falls. Nursing documentation dated [DATE], at 11:24 a.m., revealed that Resident 14 presented with increased agitation and confusion, and asking for his brother and wife who were deceased . The physician ordered laboratory studies, a urinalysis with culture and sensitivity (identifies infectious organism and most effective medication for treatment). Nursing documentation dated [DATE], at 3:00 p.m., revealed that Resident 14 had experienced increased episodes of incontinence and a urine sample for a urinalysis with culture and sensitivity had been collected. The clinical record revealed that the results of the urinalysis returned with 100,000 CFU/mL E. Coli and that the sensitivity (report that identifies most effective antibiotic to treat identified organism) remained pending. Review of culture and sensitivity final results dated [DATE], indicated that the resident's urine was positive for >100,000 CFU/mL Escherichia Coli organism and 50,000 to 100,000 col/mL Methicillin Resistant Staphylococcus Aureus (MRSA). There was no documented evidence that the physician was notified of the urine culture and sensitivity results or that the resident's identified urinary tract infection was treated. Interview with the Director of Nursing on [DATE], at approximately 1:30 p.m. confirmed that the facility failed to notify the physician of the urine results and obtain orders for treatment of the resident's urinary tract infection. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 11 of 19 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 09/08/2023 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interview and a review of employee credentials, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Residents Affected - Many Findings include: An interview with the facility's Dietary Manager on September 6, 2023, at 9:26 AM, revealed that she was previously a cook at the facility and became the dietary manager after the resignation of the CDM (Certified Dietary Manager) resigned, but confirmed that she had no experience as a manager in food service. She reported that she did not possess a CDM certificate but intended on enrolling and completing the program. Further interview with the Dietary Manager revealed that the facility used the services of two registered dietitians (RD), Employees 4 and 5, that provided part-time coverage by a registered dietitian. However, both Employee 4 and Employee 5 only performed clinical nutrition duties and provided no oversight in the dietary department. During an interview with the Nursing Home Administrator (NHA) on September 6, 2023, at approximately 10:00 AM, it was revealed that a newly hired CDM began working at the facility on June 5, 2023, but abruptly resigned on June 9, 2023. The NHA stated that the facility employed two RDs that covered provided approximately forty hours during a two-week pay cycle. A review of the facility provided Employee Time Report dated June 18, 2023, through August 26, 2023, revealed that Employee 4 worked an average of 26.2 hours per pay period. A Review of Employee 5's Employee Time Report dated June 18, 2023, through August 26, 2023, revealed that the employee worked an average of 6.8 hours per pay period. Further review of the facility's dietitian time reports revealed that they worked a combined total average of 33 hours in a two week pay period and did not work full-time hours weekly. Interview with the NHA on September 8, 2023, at 10:15 AM, confirmed that the facility's the current dietary manager does not possess all the regulatory requirements for a qualified dietary services manager and should have oversight from full-time registered dietitian(s) for oversight of the food and nutrition services department. Refer F812 28 Pa Code 201.18 (e)(1)(6) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 12 of 19 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 09/08/2023 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 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 that 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 and two of three resident pantries. 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 a facility policy entitled Food/Chemical Storage that was last reviewed by the facility June 2023, indicated that all food storage areas will be maintained in a clean, safe, and sanitary manner. Food storage areas such as, walk-in cooler, walk-in freezer, dry storage/spices shall be clean at all times, foods stored shall be stored six inches above the floor, all items taken out of the original package will be dated with month/date/year (ex 8/30/10), all food items will be closed securely or covered, and bulk items removed from its original packaging must be identified with the month/date/year. Opened spices/condiments are dated with the month/date/year and if greater than 6 months old from the open date will be discarded. Mops and brooms shall be hung on hooks and chemicals and cleaning equipment must be stored six inches above the floor, on shelves, and dollies. The initial tour of the kitchen was conducted with the facility's dietary manager on September 6, 2023, at 9:26 AM, revealed unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness. The following dietary concerns were identified during tours of the facility's kitchen area: Upon entering the walk-in refrigerator/produce cooler there were two cases of thawed orange juice cups stored directly on the floor and an open rack of uncovered portioned brownies on metal trays Observations in the walk-in refrigerator revealed foods stored beyond their use by date to include: a metal pan of chicken parmesan dated August 30, 2023 (should have been discarded Sept. 2, 2023), a large plastic container of fruit salad was dated as opened August 9, 2023 (should have been discarded 26-days ago), 2 - 2 gallon jar of pickles dated February 27, 2023, a one-gallon jar of maraschino cherries that were opened on December 5, 2022, a one-gallon plastic container of mayonnaise that was opened on June 12, 2023, a Ziplock bag with English muffins dated August 25, 2023, a plastic bag of sliced cheese dated August 23, 2023, and a Ziplock bag with a sliced tomatoes dated August 23, 2023. The following items were opened and not dated: 32-ounce container of almond milk, a Zip-lock bag of hot dogs, a Zip-lock bag of sausage links, a Zip-lock bag of roast beef, a Zip-lock bag of hard-boiled eggs, and a one-gallon container of BBQ sauce was opened and not dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 13 of 19 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 09/08/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The dietary manager confirmed that all opened food items should have an open date listed and discarded after 3-days per facility policy and confirmed that the above items were beyond their use by/discard date or were not dated to determine acceptable storage time or use by dates. In the walk-in freezer there were several cases of food items placed directly on the freezer floor. An orange substance was observed frozen to the floor. The vents on the right side of the ice machine were coated with an accumulation of dust and debris. Observations of the preparation/beverage station revealed that inside of the microwave there were two plastic thermal cups with a hot dog in each. The dietary manager stated the hot dogs were from dinner last night and confirmed that staff forgot to discard and clean the microwave. Observations of the preparation/beverage station revealed a large plastic storage bin containing an open bag of dry lentils that was not dated. The plastic bin lid was observed to be ajar and the top of the lid was stained and coated with an accumulation of debris. Another plastic bin contained an open sleeve of plastic cup lids that were not covered. Observations of the cook's spice and dry ingredients rack revealed that there were two open containers of chicken and beef base that were opened and undated, and also not refrigerated as indicated by the manufacturer's label. The dietary manager confirmed that bases should be refrigerated after being opened and wasn't sure when the bases were opened as containers were undated. Further observations of the cook's spice/dry ingredients rack revealed that there was an open plastic squeeze bottle of grape jelly and an open plastic squeeze bottle of chocolate syrup that were not dated and not refrigerated after opening as per the manufacturer's directions. 21 spices/dry ingredient containers were opened and not dated to assure maintenance of flavors. The dietary manager confirmed that these items were opened and that each container should have been dated as per facility policy. Observations of the janitor's closet revealed that there was a mop bucket with dirty water and the dirty mop left in the bucket. There were several mops and brooms on the floor, leaning against the wall, and not hanging. Several cases of chemicals and cleaning supplies were stored on the floor. The dietary manager confirmed that these items stored in the janitor's closet were not stored properly. Observations of the dry storage area revealed that the lid to the plastic bin used to store flour was ajar and not secured and dated when filled. Further observations of the dry storage area revealed three cases of hot/cold Styrofoam bowls and cases of straws and cups stored directly on the floor. The dietary manager confirmed that these items in the dry storage area were not stored properly. Observations of the lunch meal conducted on September 6, 2023, at 12:10 PM, revealed that on top of the meal carts there were thawed 4-ounce vanilla shakes that did not have a thaw or discard date noted on the containers. The manufacturer's label noted the nutritional shakes and drinks were to be used within 14 days of thawing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 14 of 19 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 09/08/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm During an interview with the Nursing Home Administrator (NHA) on September 6, 2023, revealed that the dietary department had recent personnel changes. The NHA confirmed that the dietary department and resident pantry area were to be maintained in a sanitary manner to prevent potential contamination of food and storage items. Residents Affected - Many 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.6 (f) Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 15 of 19 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 09/08/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records and staff interviews it was determined that the facility failed to demonstrate coordination of services in the development of the comprehensive plan of care between the facility and a Hospice agency for one resident out of one sampled receiving hospice care (Resident 48). Findings include: Review of Resident 48's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease [(COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs with symptoms that include breathing difficulty, cough, mucus (sputum) production and wheezing. It's typically caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke], fracture of the left femur, and anxiety. A nurse progress Skilled Documentation dated July 13, 2023, at 1:13 PM, revealed that the Resident 48 had increased complaints of anxiety, SOB (shortness of breath), and pain of her ribs post a previous fall in her room. Medication administered as ordered. Morphine [belongs to the group of medicines called narcotic analgesics (pain medicines) used to treat pain severe enough to require daily, around-the-clock, long-term opioid treatment and when other pain medicines did not work well enough or cannot be tolerated]. Due to continued anxiousness, nursing staff notified the physician and hospice [care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure. The goal is to enable patients to be comfortable and free of pain] and with new orders to increase her antianxiety medication. Additionally, the progress note indicated that the hospice nurse would be in to see the resident on July 10, 2023. A review of Resident 48's physician's orders conducted during the survey ending September 8, 2023, revealed that there was no documented evidence that the facility obtained a physician's orders for hospice services. A review of Resident 48's plan of care conducted during the survey ending September 8, 2023, revealed hospice services was not integrated into the resident's care plan to coordinate the delivery of daily care between hospice and facility staff to meet the resident's needs. There was no evidence that the hospice and the nursing home developed a coordinated plan of care for the resident receiving hospice services to identify the provider responsible for performing each or any specific services/functions that have been agreed upon and the location of the necessary plans for delivery of resident care. During an interview with the Director of Nursing (DON) on September 8, 2023, at 9:25 AM, confirmed that the facility failed to obtain physician's orders for hospice services and that the facility failed to develop and integrate a hospice plan of care for Resident 48. 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 16 of 19 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 09/08/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the statement of deficiencies from the survey ending August 16, 2023, and the activities of facility's quality assurance committee and staff interviews it was determined that the facility failed to implement plans to correct a quality deficiency related to accidents, accident hazards and supervision and to ensure that corrective action plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies. Findings included: During a revisit survey completed at the facility on August 16, 2023, deficient facility practice was identified under the requirement for maintaining an environment free of potential accident hazards related to providing potential means of egress to allow residents to elope from the facility. In response to that quality deficiency the facility developed a plan of correction, to include a quality assurance monitoring component to ensure that solutions to the deficiency were sustained. This plan was to be completed by August 27, 2023. According to the facility's plan of correction for the deficiency cited under accidents during the survey of August 16, 2023, the patio gate door was checked by the maintenance staff and adjustments needed were completed. The lounge door to the outside patio will always remain closed. If residents, family members, or visitors need to access the lounge door to the outside patio the facility staff will assist. Facility staff have been in-serviced on the procedure for all exit doors, patio door, and patio gate in the event of power outage. Facility staff have been in-serviced on the importance of the lounge door to the outside patio always remaining closed and not propped open. When a power outage occurs maintenance/designee will complete a check of all exit doors, outside patio lounge door, and the patio to ensure they are functioning properly. The NHA/designee will complete a daily audit x 4 weeks to ensure that the lounge door to the outside patio is not propped open and remains closed unless assisted by staff. However, at the time of this revisit survey ending September 8, 2023, there was no evidence that the facility had implemented an effective corrective action plan to prevent resident elopement as evidenced by continued deficient facility practice under this same quality of care requirement. Review of a facility policy entitled Wandering and Elopements that was last reviewed by the facility June 2023, indicated that the facility will identify residents who are at risk for unsafe wandering which includes leaving the premises or a safe area without authorization, knowledge, and supervision. If an employee observes a resident leaving, he/she should attempt to prevent the resident from leaving in a courteous manner. A review of Resident 10's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder [is a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder], cognitive communication deficit [may occur after a stroke, tumor, brain injury, progressive degenerative brain disorder, or other neurological damage, which may result in difficulty with thinking and how someone uses language], and major recurrent depressive disorder [is a mood disorder that causes a persistent feeling of sadness and loss of interest and affects how one feels, thinks and behaves and can lead to a variety of emotional and physical problems]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 17 of 19 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 09/08/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 18, 2023, revealed that the resident is moderately cognitively impaired with a BIMS score (brief interview for mental status -section of MDS that assesses cognition) of 08 (a score of 8-12 indicates moderately impaired cognition) and able to walk in the corridor on the unit with supervision and setup help only with use of a walker. Additionally, section E0900. Wandering - Presence & Frequency - has the resident wandered was coded that the behavior of this type occurred 1 to 3 days during the look back period prior to the assessment date. A review of Resident 10's plan of care that was initiated on August 5, 2023, identified that the resident was an elopement risk/wanderer and had auditory and visual hallucinations related to the disease process of dementia with and behavioral disturbance, and a history of attempts to leave facility unattended with impaired safety awareness. The goal was that the resident's safety will be maintained and that the resident would not leave the facility unattended. Planned interventions were to identify pattern of wandering such as wandering purposeful, aimless, or escapist, the resident looking for something, indicate that the need for more exercise, and intervene as appropriate related to Resident 10's attempt to climb out her window. Additional planned interventions to address wandering behaviors were to re-direct and re-orient the resident when experiencing auditory and visual hallucinations and a window alarm was placed on the right side of the wall window frame/ mid window area and the actual window {alarm would sound when the window was pushed upwards to open, check for function and placement at 7:00 AM and 7:00 PM every day and prn (as needed)}. A review of a facility investigation report dated September 6, 2023, at 9:30 AM, revealed that Resident 10 was standing in the café area with her rolling walker and some personal items. She walked up to the door and Employee 1, a laundry aid/housekeeping staff, was using the code pad to enter access code to enter the front area and Resident 10 told Employee 1 that she was waiting for her ride and Employee 1 allowed the resident to go through the door to the front lobby. The Nursing Home Administrator redirected Resident 10 from the front door lobby door with assistance of the Social Service Worker. The Social Service Worker brought the resident back into the nursing unit safely. Review of Employee 1's witness statement dated September 6, 2023, indicated that at roughly 10:00 AM this morning, I went to go to grab my personal sheet from the main desk printer to start my objective in the laundry room. When I approached the doors, I noticed that there was a resident coming in. I went to inform someone at the front desk that she was attempting to come in. After grabbing my sheet, I noticed that she was in the lobby but being assisted from the people that I attempted to inform. After I assumed she was being helped, so I left. A review of Employee 1's personnel file revealed no documented evidence that the employee was trained and educated on the facility's elopement policy and procedures in effort to prevent a wandering resident from entering an area without staff supervisor. Interview with the Nursing Home Administration (NHA) on September 7, 2023, at approximately 1:30 PM, indicated that Employee 1 should not have opened the key padded locked door that led to the facility's lobby area allowing an identified wandering resident to pass through the door to an unauthorized area for a wandering area. The NHA confirmed that there was no documented evidence that Employee 1 received training on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 18 of 19 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 09/08/2023 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 0867 facility's elopement policy to protect wandering and exit seeking residents. Level of Harm - Minimal harm or potential for actual harm During an interview on September 8, 2023, at 2:00 p.m. the administrator confirmed that there was no evidence that the facility implemented an effective plan to prevent residents at risk for elopement from exiting the facility unaccompanied by staff and/or family. Residents Affected - Few The facility's quality assurance monitoring plan failed to identify this ongoing deficient practice in accident prevention and continued quality deficiency. The facility's QAPI committee failed to identify that the facility had failed to implement their plan of correction, in a manner consistent with the regulatory guidelines for the deficiency cited, to ensure that solutions to the problem were sustained. Refer F689 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 201.18 (b)(1)(e)(2)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 19 of 19