Inspection·August 8, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 42's report of bowel activity from the Documentation Survey Report for May 2024, revealed the resident did not have bowel movements on May 10, 11, 12, 13, 14, 15, 2024. (6 consecutive days). Review of Resident 42's Medication Administration Record (MAR) for May 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. Review of Resident 42's report of bowel activity from the Documentation Survey Report for July 2024, revealed the resident did not have bowel movements on July 4, 5, 6, 7, 8, 2024 (5 consecutive days) and July 23, 24, 25, 26, 2024 (four consecutive days). Review of Resident 42's Medication Administration Record (MAR) for July 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. During an interview with the Director of Nursing (DON) on August 8, 2024, at 12:05 PM, the DON confirmed the facility failed to provide nursing services consistent with professional standards and was unable to provide evidence that physician ordered bowel protocol was followed for Resident 42. Further review of Resident 42's clinical record revealed a physician's order dated March 26, 2024, for Geri-sleeves (fabric material, often lightly padded, to protect thin/fragile skin from skin tears, abrasions and light bruising) to BUE [bilateral upper extremities (arms)] at all times except for hygiene, and to check skin integrity every shift. An additional physician's order dated May 2, 2024, revealed an order for the application of TED stockings (Thrombo-Embolic Deterrent - anti-embolism stockings for the legs to help prevent blood clots) to BLE [bilateral lower extremities (legs)] one time a day for bilateral edema edema and remove per schedule. A review of Resident 42's care plan, in effect at the time of the survey ending August 8, 2024, indicated the resident was to wear Geri-sleeves on her arms at all times, and to apply TED stockings to her legs and to check skin integrity with application and removal of the devices. An observation of Resident 42 on August 7, 2024 , at 1:55 PM revealed that Resident 42 was sitting in her wheelchair in the activity room and did not have the ordered Geri-sleeves on her arms to protect her skin nor did she have the TED stockings to her legs for edema as ordered. A review of Resident 46's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis to include chronic obstructive pulmonary disease (COPD), pulmonary embolism (blood clot in one or more arteries in the lungs), and diabetes (failure of the body to produce insulin). A review of a physician's order dated May 29, 2024, revealed an order for TED stockings to be applied in the AM and remove at hours of sleep; check skin integrity with application and removal two times a day. Observation of Resident 46 on August 6, 2024, at 1:45 PM and August 7, 2024 , at 11:00 AM revealed that the resident was not wearing TED stockings on his legs as ordered at the time of each observation. (continued on next page) 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 08/08/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 48's clinical record revealed that the resident was most recently admitted to the facility on [DATE], with diagnosis to include presence of a left artificial hip joint (hip replacement), and a wedge compression fracture of the first and second lumbar vertebra (fracture occurring at the front of the spinal vertebra of the low back). A review of physician's order dated July 24, 2024, revealed an order to maintain left hip precautions every shift status post ORIF (Open reduction and internal fixation-type of surgery used to stabilize and heal a broken bone). Hip precautions are ordered following a hip replacement to prevent dislocation. General hip precautions include: Do not cross legs or ankles when sitting, standing or lying down. Keep feet about 6 inches apart and do not bring them all the way together. Avoid hip flexion (forward bending) greater than 90 degrees. Do not twist the upper body when standing or when rolling in bed (use log roll method) A review of a physician's order dated July 23, 2024, revealed an order to float heels (elevate heels above bed) every shift for prevention (prevent pressure ulcers from occurring on the heels). A review of a physician's order dated August 3, 2024, revealed an order to utilize an abductor pillow (specialty pillow used to restrict hip movement and keep hip in proper alignment as a precautionary measure to help prevent hip dislocation) between her legs at all times. A review of Resident 48's care plan, in effect at the time of the survey ending August 8, 2024, indicated that staff was to offload her heels when in bed and to utilize an abductor pillow between her legs at all times to maintain hip precautions. Observation of Resident 48 while lying in bed on August 6, 2024, at 1:00 PM revealed the resident's heels were in direct contact with the mattress and were not off loaded as ordered. The resident's left toes were pressed up against the hook of the air mattress motor which was hung over the bed footboard. Further observation revealed the resident had one bed pillow between her legs. Her knees were close together and her feet were approximately 4-inches apart, not adhering to the ordered hip precautions. No abductor pillow was positioned between her legs as ordered at the time of observation. The abductor pillow and an abductor wedge were located on the resident's floor next to the dresser drawers. Interview with Employee 1 licensed practical nurse (LPN) on August 6, 2024, at 1:10 PM confirmed the resident's heels were in direct contact with the mattress and were not off loaded. Employee 1 (continued on next page) 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 08/08/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some confirmed the resident's left lower extremity was not positioned properly and was not in adherence to the physician ordered hip precautions. A review of a facility policy entitled Measuring Resident Oral Intake last reviewed by the facility on May 23, 2024, indicated that each resident's oral intake at mealtimes and in-between meals shall be recorded and entered into the electronic medical record (eMAR - is an alternative to paper-based medical charts that serves as a legal documents collector for medical clinics and it creates and saves a record of every medicine administered to a patient over the treatment cycle). The purpose of this procedure is to accurately record the amount of food and fluids ingested by the resident after each shift. Staff will enter the amount of food and fluids into the eMAR before the end of shift by nurse aide (NA), Licensed Practical Nurse (LPN), or Registered Nurse (RN). If the resident is noted with decreased oral intake for three (3) meals or more, it is the responsibility of the nurse to report the resident's decreased oral intake to the MD/NP/PA, the registered dietitian (RD), and the resident representative (RR). A review of Resident 24's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease ( condition where plaque builds up in the arteries and can cause heart attacks, strokes, and other complications) with presence of xenogeneic heart valve (replaces a damaged valve in the heart and made from tissue sourced from animals such as pigs or cows), chronic heart failure (is an ongoing inability of the heart to pump enough blood through the body to ensure a sufficient supply of oxygen). A review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated March 21, 2024, revealed that Resident 24 was cognitively intact with a BIMS (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 7-12 equates to being moderately cognitively impaired) score of 13. A nursing progress note completed by Employee 5, a RN, dated April 24, 2024, at 9:12 p.m., revealed the resident was assessed secondary to 14.4 - pound (lb.) or 5.4% weight loss in 30 days. It was noted the resident's mucous membranes were moist, skin turgor was adequate, and the resident's appetite was fair. There were no signs or symptoms of dehydration. A fluid restriction was in place and the physician was made aware. There were no new order at the tie of the progress note. The note indicated the Dietitian was monitoring the resident. The resident is her own responsible representative and is aware of the information noted . A review of Resident 24's fluid intake report revealed that the following recorded fluids that were consume: April 25, 2024 - 810 ml, April 26, 2024 - 1290 ml recorded, April 27, 2024 - 1,930 ml recorded, April 28, 2024 - 1,410 ml recorded, April 29, 2024 - 1,320 ml, April 30, 2024 - 1,590 ml, May 1, 2024 - 390 ml, May 2, 2024 - 2,040 ml, May 3, 2024 - 600 ml, May 4, 2024 - 1,020 ml, May 5, 2024 - 1,200 ml, May 6, 2024 1080 ml, and May 7, 2024 - 600 ml. Additionally, a review of Resident 24's meal intake report revealed from April 25, 2024, through May 7, 2024, or thirty-nine (39) meals served there were twenty (20) missed entries or 48.7% of meal intakes were not recorded or assessed by staff. Documentation that the resident refused (RR) or not applicable (NA) was recorded by for three meal entries or 7.69%. Recorded meal percentages averaged approximately 20.65%. However, this documentation could not accurately assess the resident's actual meal intakes due to missed entries and not applicable documentation. (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 08/08/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm A progress note completed by Employee 6, a RN, dated May 2, 2024, at 6:44 p.m., revealed Resident 24 offered complaints of feeling tired all the time. The note indicated the resident requires assistance of two persons for transfers and with activities of daily living. The resident previously required one person for assistance, The note indicated the resident's appetite was poor and the resident reports not being able to eat and did not attend therapy in the day of this note. Residents Affected - Some A progress note written by Employee 2, the facility's registered dietitian (RD), completed on May 3, 2024, at 12:38 p.m.,revealed that Resident 24's weights were reviewed, and the resident's current weight was at 240.8 pounds and triggered for significant weight loss of 21.2 pounds within t 30 days or 8.1% weight loss. The resident's weight has been decreasing since admission. The resident's oral intakes were approximately 25-50% and the resident was ordered on diuretics (or water pill is a medication that removes extra salt and water built up in the body to improve cardiac function by increasing the need to urinate) and placed on a fluid restriction. A diet supplemented with liquid protein was ordered and the RD recommended offering the resident a 1/2 of a soft sandwich with lunch and dinner due to poor meal intake. The RD noted the resident to have lower leg edema (swelling) upon admission. The weight loss can be attributed to poor oral intakes and a decrease in edema. Nursing progress notes dated from May 2, 2024, through May 6, 2024, revealed that Resident 24 continued to have poor appetite with a need for staff to encourage fluids and that the resident's transfer status declined from an assist of one staff member to an assist of two staff members with transfers and ADLs (activities of daily living). Additionally, the nursing progress notes noted that the resident had increased urinary and bowel incontinence related to diuretics. Employee 7, a RN, completed a nursing progress note dated May 7, 2024, which identified abnormal laboratory results and indicated that Resident 24's attending physician ordered to initiate IV fluids (are specially formulated liquids that are injected into a vein to prevent or treat dehydration) of normal saline (also known as 0.9% sodium chloride solution, is a commonly used intravenous fluid in medical settings and is a sterile solution containing sodium chloride in a concentration similar to that of human blood) at 80 ml per hour and an order to redraw labs and obtain a chest x-ray on May 8, 2024. The resident agreed with the orders. A note written by Employee 8, an RN, dated May 7, 2024, at 2:23 p.m., indicated she was unable to obtain IV access (IV fluids could not be started) and the resident appeared lethargic (an unusual decrease in consciousness). The MD was made aware of the inability to administer fluids and the resident was encouraged to drink more fluids. Further review of nursing progress notes revealed that on May 8, 2024, at 3:40 a.m., Employee 9, an RN, attempted again, twice, to place the IV and was unsuccessful. The resident was encouraged to drink more fluids. Additionally, on May 8, 2024, at 10:17 a.m., Employee 10, an RN, noted that Resident 24 stated she felt awful with complaints of nausea, and vomiting. Due to the abnormal labs, increasing weakness, and change in mental status, and overall condition and the inability for the facility to provide IV fluids, the MD advised the resident to be transferred to the hospital for an evaluation. An interview with Employee 11, a RD, on August 8, 2024, at 10:56 a.m., indicated he was not employed by the facility during the time of Resident 24's changes in condition. Employee 11 confirmed that meal intake monitoring for Resident 24 was not accurate due to several missed entries and not applicable documentation. (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 08/08/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the resident's hospital records revealed that Resident 24 was admitted to the hospital on [DATE], with a critically high potassium at 6.6 mmol/L (reference range 3.5 - 5.1 mmol/L -A potassium blood test measures the amount of potassium in the blood that reflects the function of the body's cells, nerves, heart, and muscles), acute renal failure (AKI is a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days with symptoms that include legs swelling and fatigue), dehydration (occurs as a result of abnormal water loss from the body), and endocarditis (is a life-threatening inflammation of the inner lining of the heart's chambers and valves that is usually caused by an infection). The facility failed to consistently and accurately record Resident 24's food/fluid intakes and failed to timely act on changes in condition to prevent critical lab values resulting in hospitalization. An interview with the Director of Nursing (DON) on August 8, 2024, at 11:00 a.m., confirmed that Resident 24's fluid intakes were not consistently and accurately recorded, and that staff were unsuccessful with implementing IV fluids as ordered by the physician. Additionally, the DON confirmed that staff failed to timely act on Resident 24's changes in condition that resulted in critical labs and hospitalization. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(ii) Medical records 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 08/08/2024 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 review of clinical records and select facility reports, observations and staff and resident interviews it was determined the facility failed to consistently implement measures planned to promote healing, prevent worsening and the development of pressure sores for one resident out of 16 residents sampled (Resident 43). Residents Affected - Few Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of facility policy entitled New admission or New Skin Impairment Protocol, last reviewed May 23, 2024, indicated that residents admitted or whom develop skin impairment issues will receive treatment as indicated based on location, condition, and drainage. According to policy, the registered nurse will complete an incident/accident report as per policy for residents with new identified skin impairments. Each area identified will be documented on a Wound Evaluation Flow Sheet, and documentation will include measurement, exudate (drainage), wound bed, peri-wound (area around the wound), and current treatment. A review of the clinical record revealed that Resident 43 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, heart disease, and diabetes. A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 2, 2024, revealed the resident was moderately cognitively impaired and required substantial/maximum assistance from staff for transfers, dressing, personal hygiene, and toilet use and was at risk for pressure sore development. A review of the weight record in Resident 43's clinical record revealed the following record weights: March 7, 2024, at 2:32 p.m. - 127 lbs. April 1, 2024, at 9:17 a.m. - 118.6 lbs. (no re-weight recorded) April 12, 2024, at 3:02 p.m. - 110.9 lbs. (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 08/08/2024 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 May 1, 2024, at 1:48 p.m. - 110.8 lbs. Level of Harm - Minimal harm or potential for actual harm June 7, 2024, at 11:30 a.m. - 101.2 lbs. June 16, 2024, 2:20 a.m. - 97.6 lbs Residents Affected - Few A review of Resident 43's care plan initiated March 31, 2023, revealed the resident was at risk for skin breakdown related to immobility and bowel incontinence, with interventions also dated March 31, 2023, for an air mattress-and check function every shift, apply treatment per MD orders, monitor weight and notify physician of any significant weight loss, provide routine position change through weight shifting, transfer to bed/toilet, stand at intervals with assist, routine skin care during personal hygiene with application of emollient, and weekly skin assessment. A nurse's note dated June 28, 2024, at 10:50 PM, indicated that during morning care to Resident 43, a new wound was noted on the resident's sacrum area. The wound is beefy red with 25% of slough (dead tissue), minimal bleeding, and not painful. According to the documentation, the resident was not able to explain when and how the area developed. The note indicated that wound care is provided, the resident requires every two hours repositioning and the resident is scheduled for wound care consultant rounds. A review of the facility's investigation dated June 28, 2024, at 10:35 AM, revealed that prior to June 28, 2024, the skin concern was not identified by staff who were providing care to the resident. According to the investigation, a treatment order was obtained from the physician on June 28, 2024 to cleanse the resident's sacral wound with normal saline, and apply medihoney every day shift for Stage 3 pressure ulcer (pressure sores that have progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below). There was no evidence that during the facility investigation the wound was evaluated for size, drainage, or condition of surrounding tissue. Review of Resident 43's clinical record revealed that on July 1, 2024, the resident was sent to the emergency room due to a change in condition. Hospital documentation dated July 1, 2024, at 4:13 PM indicated that due to the resident being sent to the hospital, consideration for air mattress upon return was recommended. However, according to the current plan of care, an air mattress had been implemented since March 2023. Although the resident was identified with a significant weight loss and risk factors which increased the resident's risk of pressure ulcers the facility did not implement additional measure to prevent the development of a pressure ulcer. Interview with the interim Director of Nursing on August 8, 2024, at approximately 2:10 PM, confirmed that the facility failed to evaluate Resident 43's pressure area and implement the facility's Skin Impairment Protocol by failing evaluate the sacral area. Refer F692 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 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 08/08/2024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 select facility policies, and staff interviews, it was determined that the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and failed to develop/revise and implement effective nutrition management interventions to prevent further significant weight loss and dehydration for one resident out of six residents sampled with weight loss (Residents 43). Residents Affected - Some Findings included: A review of facility policy titled Resident Heights and Weights, last reviewed by the facility on May 24, 2024, indicated that the facility would utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss in residents. Resident weights were recorded in the electronic health record and a reweight was obtained for any residents whose weight fluctuated by plus (+) or minus (-) five pounds (lbs.) for those over 100 lbs. and plus or minus three pounds for those weighing less than 100 lbs. Any resident being tracked as at nutritional risk for significant weight loss or sudden poor intake, shall be weighed weekly or as specified by the registered dietitian. A review of Resident 43's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by problems with metabolism, such as low glucose or high toxins), muscle weakness, and Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). A review of Resident 43's comprehensive person-centered plan of care that was initiated on October 3, 2023, and revised on February 6, 2024, identified that the resident had a nutritional problem related to need for a therapeutic diet, diagnoses of hypertension and diabetes, and resident goal to maintain adequate nutritional status as evidenced by maintaining weight within +/-5# and no signs or symptoms of malnutrition. Planned interventions included to monitor/record/report to MD as needed (PRN) signs and/or symptoms of malnutrition such as emaciation(abnormally thin) or Cachexia (weakness and wasting of the body due to severe chronic illness,) muscle wasting, significant weight loss: 3-pounds in 1 week, greater than (>) 5% in 1 month, greater than (>) 7.5% in 3 months, greater than (>) 10% in 6 months, and RD to evaluate and make diet changes and recommendations PRN. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 28, 2024, revealed that Resident 43 was cognitively intact with a BIMS score of 13 (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 the weight record in Resident 43's clinical record revealed the following record weights: March 7, 2024, at 2:32 p.m. - 127 lbs. April 1, 2024, at 9:17 a.m. - 118.6 lbs. (no re-weight recorded) April 12, 2024, at 3:02 p.m. - 110.9 lbs. (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 08/08/2024 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 0692 May 1, 2024, at 1:48 p.m. - 110.8 lbs. Level of Harm - Minimal harm or potential for actual harm June 7, 2024, at 11:30 a.m. - 101.2 lbs. June 16, 2024, 2:20 a.m. - 97.6 lbs. Residents Affected - Some A review of a progress note completed by Employee 2, Registered Dietitian (RD), dated April 10, 2024, at 1:36 p.m., revealed weight was at 118.6-pounds and triggered for significant weight loss of 8.4-pounds in 30 days. The RD documented that a re-weight was needed. Further review of Resident 43's weight record revealed that on April 12, 2024, at 3:02 p.m., a new weight was obtained and the resident now weighed 110.9 lbs.This signified a further weight loss of 7.7-pounds or 6.4% in 2-weeks and a loss of 16.1-pounds or 12.7% in greater than 30-days. A review of a nutritional assessment initiated by Employee 2 on April 3, 2024, and signed by Employee 2 on April 12, 2024, at 1:08 p.m., revealed that Resident 43 was receiving a NAS (no added salt), CCHO (consistent carbohydrate) diet, regular texture, and thin liquids with fortified shakes (high calorie high protein supplement) twice (BID) per day with good acceptance. Employee 2 noted that the resident's current appetite was fair and historically good appetite. Weight: 118.7-pounds (April 1, 2024, at 9:17 a.m.) and usual body weight 115 - 120 pounds. Employee 2 indicated a weight loss of 8-pounds in 30 days. Further review of Resident 43's nutrition progress notes in the clinical record completed by Employee 2, dated April 17, 2024, at 11:20 a.m., revealed that a re-weight was obtained, and additional weight loss noted. The RD documented the residents current weight was110.9-pounds and oral intakes were inconsistent at 0-100%. zTHe RD documented that Remeron (appetite stimulant medication) was discontinued in March and weight loss was most likely attributed to decreased oral intakes related to the discontinuation of Remeron (appetite stimulant). The plan was to discuss the implementation of an appetite stimulant with the IDT (interdisciplinary team). A review of Resident 43's physician's orders dated April 19, 2024, at 2:13 p.m., revealed an order for Mighty Shake (high calorie/high protein oral supplement) twice per day was ordered related to weight loss. Further review of physician's orders dated April 21, 2024, at 12:26 p.m., revealed an order for Megace ES (an appetite stimulate medication) oral suspension 625 milligrams per 5 milliliters (ml), give 5 ml by mouth two times a day for appetite stimulant was also included. A review of a nutrition/dietary note completed by Employee 2 on May 3, 2024, at 8:36 a.m. revealed that weights were reviewed and current weight at 110.8-pounds with significant weight loss of 7.8-pounds (6.6%) in 30 days. BMI (body mass index) within normal limits at 20.3. Resident has a history of weight fluctuations. Oral intakes 50-100% and diet supplemented with mighty shakes twice per day and consumes 100%. Employee 2 recommend increasing shakes to three times per day. Megace was started on April 22, 2024 and the plan was to continue to monitor. Resident 43's weight record revealed that on June 7, 2024, at 11:30 a.m., the resident's weight had deceased to 101.2-pounds., and on June 16, 2024, at 2:20 a.m., the resident weighed 97.6-pounds. A review of a nutrition/dietary note completed by Employee 2 on June 17, 2024, at 3:16 p.m., (continued on next page) 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 08/08/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed that Resident 43 had weight loss of 26-pounds (20.9%) within five months. BMI low at 17.8. Current weight 97.6-pounds and oral intakes poor. Seen by speech therapy and needs assistance during meals to promote increased intakes. Diet supplemented with mighty shakes with meals and recommend Boost Glucose (diabetic oral nutritional supplement) Control twice per day. A nursing progress notes in Resident 43's clinical record completed by Employee 3, a Licensed Practical Nurse (LPN), on June 30, 2024, at 1:56 p.m., revealed that the resident was very sleepy during lunch time and when attempting to feed the resident, food would come back out of mouth, resident was also having difficulty drawing up liquids through a straw. Employee 3 sent communication to speech therapy for re-evaluation. Further review of nursing progress notes completed by Employee 4, a RN, dated July 1, 2024, at 12:34 p.m., revealed that orders were obtained from the attending physician to send the Resident 43 to the emergency department for evaluation. A review of Resident 43's hospital records dated July 1, 2024, at 12:54 p.m., revealed that the resident was admitted to the hospital with diagnoses of urinary tract infection, AKI (acute kidney injury - a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days and symptoms include legs swelling and fatigue) secondary to dehydration (occurs when the body loses more fluid than consumed, and does not have enough water and other fluids to carry out normal functions), hypotension (low blood pressure), and insertion of a feeding tube (is a flexible plastic tube placed into the stomach or bowel to help with getting nutrition when unable to eat as well as needed to improve or maintain nutritional status) to meet nutrition and hydration needs. Resident 43's clinical record failed to reveal that weights and re-weights were timely obtained, assessed, and monitored to timely develop/revise and implement effective nutrition management interventions to prevent further significant weight loss and dehydration. Additionally, the RD failed to evaluate the continued effectiveness of nutritional interventions and demonstrate that alternative methods and approaches for delivery of nutrition and hydration were presented and discussed with the resident whose cognition was intact, the resident representative with the resident's permission, interdisciplinary team (IDT), and attending physician, to deter progressive significant weight loss and dehydration. During an interview with the facility's Director of Nursing (DON) on August 8, 2024, it was confirmed that weights and re-weights were not timely obtained as indicated in the facility's height and weight policy and that the facility failed develop/revise and implement effective nutrition management interventions to prevent further significant weight loss and dehydration. Also, the DON confirmed that the facility failed to timely identify and address Resident 43's declining oral intakes that resulted in progressive significant weight losses with need for hospitalization and placement of a feeding tube. 28 Pa Code 211.10 (c) Resident care policies. 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 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 08/08/2024 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 0698 Provide safe, appropriate dialysis care/services 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 observation, a review of clinical records, and resident and staff interview, it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one resident out of one sampled receiving hemodialysis (Resident 218). Residents Affected - Few Findings include: According to the National Kidney Foundation, patients receiving hemodialysis( a life saving treament for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure) should keep emergency care supplies on hand. A review of the resident's clinical record revealed that Resident 218 was admitted to the facility on [DATE], with diagnoses to include end stage renal disease, and dependence on renal dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Resident 218's clinical record indicated he was receiving hemodialysis through an Ash Cath(type of vascular access hemodialysis catheter) in his left arm (dialysis access site) for dialysis access every Monday, Wednesday, and Friday. Resident 218's clinical record revealed a physician order dated July 29, 2024, for an emergency kit at bedside for the dialysis access site . The resident's plan of care, dated July 30, 2024, indicated that Resident 218 required dialysis due to end stage renal disease. The care plan did not include interventions planned for emergency care of the Ash Cath to include an emergency dialysis kit at bedside despite the physician's order. Observation conducted on August 6, 2024, 12:45 PM revealed no emergency kit or supplies available at the resident's bedside. Interview with Resident 218 in his room on August 6, 2024, at 12:45 PM indicated that the resident never saw or was informed of an emergency kit for his dialysis site in his room since admission on [DATE]. Interview with the Director of Nursing (DON) on August 6, 2024, at 2:07 PM revealed that each resident in the facility receiving dialysis should have emergency supplies at bedside. The DON confirmed that there were no emergency supplies available at Resident 218's bedside and that facility failed to assure an emergency kit was readily available in the event of an emergency with the resident's dialysis access site. 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 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 08/08/2024 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, payor source data, and staff interview, it was determined that the facility failed to promptly refer a resident with a broken bridge for dental services for one Medicaid payor source resident (Resident 4) and failed to provide dental services for a resident with poor dentition and high-risk diagnosis (heart valve) with Medicaid as payor source (Resident 24). Residents Affected - Few Findings included: Review of the clinical record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses to include diverticulitis (inflammation or infection in one or more small pouches in the digestive tract), and hypertension (high blood pressure-force of blood against the artery walls is too high). Review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated May 19, 2024, revealed that Resident 4 was moderately cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 7-12 equates to being moderately cognitively impaired). Review of a nurses note dated July 1, 2024, at 7:12 AM revealed that the resident's upper bridge( fixed or removable dental restoration used to replace one or more missing teeth by joining an artificial tooth definitively to adjacent teeth or dental implaints) broke off. It was documented that Resident 4's representative was notified. A speech therapy note dated July 3, 2024, at 3:18 PM revealed that the resident was screened for two noon meals due to the broken dentaql appliance. The Speech Therapist determined that the resident was able to safely manage a regular texture diet and was scheduled to see a dentist on July 17, 2024. The speech therapy plan was to follow-up with the resident after the dental consult. There was no further documentation in the resident's clinical record regarding the completion outcome of the appointment or the reason why the appointment had not been completed as scheduled. A review of the resident's clinical record, revealed there was no indiction the Speech Therapist had followed-up after the intended July 17, 2024 appointment to review Resident 4 for meal texture tolerance or to identify the resident did not have a repaired dental appliance. There was no documented evidence that a repair or replacement of Resident 4's upper bridge had been completed at the time of the survey ending August 8, 2024. During an interview on August 8, 2024, at approximately 1:15 PM the Director of Nursing (DON) was unable to provide documented evidence that the facility had provided timely and necessary assistance to obtain dental services needed by the resident to repair or obtain a new/replacement bridge. A review of Resident 24's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease (is a condition where plaque builds up in your arteries and can cause heart attacks, strokes, and other complications) with presence of xenogeneic heart valve (replaces a damaged valve in the heart and made from tissue sourced from animals such as pigs or cows). (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 08/08/2024 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident 24's clinical record admission assessment section D. Oral/Nutritional dated March 14, 2024, at 4:47 p.m., revealed that had broken/carious teeth and broken bottom dentures. Review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated March 21, 2024, revealed that Resident 24 was cognitively intact with a BIMS score of 13. A review of Resident 24's clinical record revealed that the resident was admitted to the hospital on [DATE], and diagnosed with endocarditis (is an inflammation of the inner lining of the heart chambers and valves that is usually caused by bacterial infection. Further review of Resident 24's cardiology consults included in the hospital records dated May 8, 2024, revealed cardiologist findings that the resident had poor dentition and her heart valve had large amounts of mobile vegetation (growths on the heart valves that produces toxins and enzymes that kill and break down the tissue to cause holes in the valve, and spreads outside of the heart and blood vessels present). Resident 24's clinical record failed to reveal that the facility arranged/provided dental services to address the resident's poor dental condition which had been identified on Resident 24's MDS and during hospitalization. During an interview with the facility's Director of Nursing (DON) on August 8, 2024, at 11:30 a.m., confirmed that dental services were not provided to Resident 24 to prevent hospitalization with infection related to poor dental condition. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing service 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 08/08/2024 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of select facility policy, meal delivery times, snack listing and resident and staff interviews, it was determined that the facility failed to routinely offer evening snacks to four of four residents interviewed (Residents 4, 3, 40, and 27) and failed to offer a nourishing snack to all residents when the dinner meal is greater than 14 hours before breakfast is served. Findings include: Review of the facility policy titled HS Snack Policy last reviewed by the facility on May 23, 2024, indicated that all residents, unless medically contraindicated, will be provided a nourishing snack at bedtime daily. A nourishing snack means items from the basic food groups, whether singly or in combination with each other. During a group meeting with residents conducted on August 7, 2024, at 10:00 a.m. four out of four residents (Residents 4, 3, 40, and 27) in attendance, stated that they are not offered snacks during the evening hours before bed as desired. Resident 40 stated I've been here for several months, and they haven't offered snacks. Resident 27 stated that the facility staff used to come around with a cart after supper and ask what you wanted. That was so nice, but they don't do that anymore. All other residents in attendance agreed that no one ever offers them an evening snack. Review of meal tray delivery times revealed: Hallways: Dinner delivery finish time is 5:00 PM and breakfast delivery finish time is 7:45 AM (14 hours 45 minutes). Dining room: Dinner delivery finish time is 5:15 PM and breakfast delivery finish time is 8:00 AM (14 hours 45 minutes). The dinner meal is greater than 14 hours before breakfast is served, therefore a nourishing snack must be provided. A nourishing snack means items from the basic food groups (carbohydrate, protein and fat), either singly or in combination with each other. Review of the HS snacks sent to the nursing unit revealed the following snacks delivered: 8- Magic cups 8- ice cream 8- lactose free ice cream 15 - milk 15 - chocolate milk 8 - yogurts (continued on next page) 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 08/08/2024 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 0809 20 - sandwiches Level of Harm - Minimal harm or potential for actual harm 1 - Gluten free sandwich 15 - juices Residents Affected - Some 2 - bottles of honey thicken liquids (if applicable) 2 - bottles of nectar thicken liquids 2 - bottles of nectar thicken liquids 2 - honey milk 20 - assorted crackers 20 - assorted cookies/chips 5 - fruit Observation on August 8, 2024 at 11:45 AM of the snack bins behind the nursing station revealed one rice crispy treat and 15 peanut butter crackers. Observation of the locked refrigerator/freezer revealed 4 sandwiches, 3 juices, and 4 milks. There was no evidence that each resident on the nursing unit was offered a nourishing snack because the mealtimes were greater than 14 hours. During an interview with the Registered Dietítian on August 8, 2024, at approximately 10:30 AM, he was unable to explain why the residents are not consistently offered a nourishing snack at bedtime due to the interval of more than 14 hours between dinner and breakfast. 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 08/08/2024 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and reports, clinical records and resident and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events as evidenced by one resident out of 16 sampled (Resident 41). Residents Affected - Few Findings include: Review of the facility policy entitled Quality Assurance and Performance Improvement Plan last reviewed by the facility on May 23, 2024, revealed that the facility will put in place systems to monitor care and services, drawing from data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also will include tracking, investigating, and monitoring adverse events every time they occur, and action plans implemented through the plan. Goals of the QAPI plan include: 1. The facility will place proper infection control prevention to prevent or decrease the number of COVID-19 positive residents. 2. The facility will create a QAPI team and a QAPI program to address needs, concerns, and tracking and trending events. 3. The facility will continue to train staff to include competencies, in person education, mentoring, and written education. The QAPI approach/plan will also be communicated to consultants, contractors, and collaborating agencies, to ensure they understand that they each have a role in the QAPI plan. Clinical record review revealed that Resident 41 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following stroke affecting left non-dominant side, aphasia (language disorder that affects a person's ability to communicate) following stroke, and dementia (the loss of cognitive functioning like thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of an Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 30, 2024, revealed that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 10 (score of 8-12 indicated that the resident was moderately cognitively impaired), and (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 08/08/2024 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 0865 required extensive assistance to perform toileting and bed mobility tasks. Level of Harm - Minimal harm or potential for actual harm Review of the resident's care plan, dated June 6, 2023, revealed that she required the assist of one person for toileting and commode over toilet, the assist of one person with med mobility, and the assist of one person to move between surfaces using a rollator walker. Residents Affected - Few A nurses note dated June 9, 2024, at 9:07 AM indicated that Employee 13, registered nurse (RN), was called to the resident's room by Employee 1, licensed practical nurse (LPN). According to the note, while Employee 1 performed the resident's morning blood sugar check, the resident was grimacing in pain. The resident was then noted to be guarding her left arm and shoulder and refused an assessment of the left arm and shoulder. When asked to lift her left arm, the resident yelled in pain. The physician ordered an x-ray of the left shoulder. Results of x-ray determined that Resident 41 had dislocation of left proximal humerus, and orders were received to send the resident to the emergency room for an evaluation. A nursing progress note dated June 10, 2024, at 12:34 AM, indicated that the hospital performed a closed reduction of the left shoulder and that the resident would be returning to the facility from the hospital with an immobilizing sling to remain in place until seen by orthopedic doctor. Review of the facility incident report dated June 9, 2024, at 2:39 PM revealed that Resident 41 had shown evidence of pain when the nurse performed morning blood sugar check. The resident was found to be guarding her left arm and shoulder with x-ray results identifying a dislocation of the left proximal humerus. Review of the witness statement from Employee 1 (LPN) dated June 9, 2024 (no time indicated) revealed that on June 7, 2024, there were no concerns identified with Resident 41.It was indicated the resident was out of bed in her wheelchair throughout the shift and participated in activities. On June 8, 2024, according to Employee 1, Resident 14 was behavioral during a.m. care and blood sugar checks, resident shouting when being touched and did not want to get OOB [out of bed], shouting 'no, no, no'. The resident had recently begun an antibiotic for a urinary tract infection and remained in bed during shift resting and sleeping intermittently. Additionally, Employee 1 stated that on June 9, 2024, during morning care, Resident 41 was shouting and would not remove right hand off left arm and left shoulder, guarding area and grimacing. Employee 1 further stated that the resident was unable to answer appropriately. Review of the witness statement from Employee 12, nurse aide (NA), indicated that on June 6, 2024, she went into Resident 41's room to change her (no time indicated) and when she rolled the resident to the left, the resident made a sound. When asked if she was ok, the resident placed her hand on left shoulder. According to Employee 12, the resident stated she was ok, and that Employee 12 told the nurse on that hall (no nurse was named). Review of additional witness statements failed to provide evidence that any nurse was notified that Resident 41 had complained of pain or Employee 12's impression she heard an odd sound when rendering care on June 6, 2024. There was no evidence that any nursing staff recalled the resident complaining of pain prior to the concern identified on June 9, 2024. Review of witness statement obtained by Resident 41 by the Director of Nursing on June 10, 2024, at 2:30 PM, indicated that the resident could not recall what led to the injury, she shook her head (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 08/08/2024 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 0865 no. The resident stated no when asked whether anyone hurt her or had been rough with her. Level of Harm - Minimal harm or potential for actual harm Review of significant change MDS dated [DATE], revealed that Resident 41 had a decline in cognitive ability. The resident was identified as having a BIMS of 1, which indicated severe cognitive impairment. Residents Affected - Few Surveyor attempted to interview Resident 41 on July 8, 2024, at approximately 9:30 AM, but was unable to obtain any information related to her previous shoulder injury. The resident response was unintelligable when she was interviewed. Review of investigation results completed by the facility, revealed that on June 13, 2024, education was provided to Employee 12 related to bed mobility training with repeat/return demonstration. There was no evidence that during the facility investigation, concerns were identified with how Employee 12 provided care to Resident 41. Further review of facility findings during the investigation, the facility determined that the nurse aides caring for resident explained how they assist the resident with transfers, toileting, and bed mobility. When toileting the resident used the upper grab bar with her left hand and her arm to pull up and the lower grab bar to assist with pushing up from her wheelchair and assisted in standing to pivot and place herself on the toilet. There were no statements or evidence available at time of survey ending August 9, 2024, that observations and/or demonstrations were performed to identify or rule out this technique, as a root cause or potential cause for the injury sustained by Resident 41. There was no evidence available at time of survey ending August 9, 2024, that the facility identified that Employee 12 failed to perform bed mobility in a safe manner or what concerns were identified that led to the required education. The facility was unable to show any corrective actions developed as a result of the QAPI review of this event, as the investigation was incomplete. There was no evidence that the facility had fully investigated the circumstances surrounding the resident's injury to fully ascertain the underlying cause or contributing factors to this incident and to demonstrate the facility's good faith efforts to prevent injury to residents. There was no evidence at the time of the survey that the facility demonstrated an effective QAPI program to include outcomes of quality of care and quality of life by investigating resident incidents and maintaining thorough documentation to support their analysis of the data collected and any corrective actions developed and implemented. 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(4) Management 28 Pa. Code 211.12(c) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396148 If continuation sheet Page 19 of 19