Health inspection·May 24, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm To identify other residents that have the potential to be affected, the Regional Director of Clinical Services (RDCS) or designee we'll review progress notes going back 30 days to identify if any events occurred that required an incident and accident report. If identified that one was not completed, it will be completed and the physician and responsible party will be notified. Residents Affected - Few o to identify like residents that have the potential to be affected, the Social Worker (SW) or designee we'll interview capable residents to identify if they had fallen in the past 30 days. The facility will review the results of those audits and if a resident answered yes the facility will ensure that physician and responsible party notification was completed. o To prevent this from happening again the nursing home administrator or designee will educate the licensed nursing staff when a resident has a fall that an incident report must be completed, an RN must assess the resident, and the physician and responsible party must be notified. o To monitor and maintain ongoing compliance the social worker or designee will interview 5 capable residents weekly for 4 weeks then monthly for 2 months to identify if they had fallen in the past week. The RDCS or designee will review results of the audits to correlate a yes response to the incident and accident report being completed and to ensure that the physician and responsible party was notified. The result of the audit will be forwarded to the facilities quality assurance committee for further review. The completion date for this plan of correction was April 22, 2023. 28 Pa Code 211.12 (a)(c)(d)(3)(5)Nursing services 28 Pa. Code 211.10(a) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 2 of 4 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 395644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Valley Health Care Center 81 Sturges Road Peckville, PA 18452 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and select incident reports, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure a registered nurse timely assessed a resident after fall and provided necessary nursing care for one resident (Resident 1) out of 9 residents reviewed experiencing an unwitnessed fall. Residents Affected - Few Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. A review of the clinical record revealed that Resident 1 was admitted into the facility on June 23, 2022, with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). A review of a nursing note dated for April 15, 2023, at 9:00 AM, but entered into the clinical record late on April 18, 2023, at 10:29 PM revealed Resident 1 had an unwitnessed fall. According to this late entry nurse's note, nursing staff found the resident on the floor of the resident's room. Employee 1 LPN (license practical nurse) noted that she helped the resident up and evaluated him and noted there was no injury noted at that time. A review of the resident's clinical record revealed no documented evidence that Employee 1 notified the Registered Nurse on duty at the time of the resident's fall or documented evidence that a registered nurse had conducted an assessment of the resident after the unwitnessed fall. Interview with the Nursing Home Administrator on May 24, 2023, at approximately 10:00 AM confirmed there was no documented evidence in the resident's clinical record that the facility's professional nursing staff had timely assessed after a fall. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: o Resident 1 had an assessment completed by a nurse on April 17, 2023. The resident had pain on April 18, 2023, and the physician was notified, and new orders were noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 3 of 4 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 395644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Valley Health Care Center 81 Sturges Road Peckville, PA 18452 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 o Level of Harm - Minimal harm or potential for actual harm To identify other residents that have the potential to be affected, the Regional Director of Clinical Services (RDCS) or designee will review incident and accident report going back 30 days to ensure a Registered Nurse assessment was completed Residents Affected - Few o To identify like residents that have the potential to be affected, the Social Worker (SW) or designee will interview capable residents to identify if they had fallen in the past 30 days. The facility will review the results of those audits and if a resident answered yes, the facility will ensure that Registered nurse assessment was completed. o To prevent this from happening again the nursing home administrator or designee will educate the licensed nursing staff that when a resident has a fall that an incident report must be completed, an RN must assess the resident, and the physician and responsible party must be notified. o To monitor and maintain ongoing compliance Director of Nursing or designee will review incident and accident reports weekly for 4 weeks then monthly for 2 months to ensure the Registered Nurse assessment is completed. The result of the audit will be forwarded to the facilities quality assurance committee for further review. The facility's completion date for this plan of correction was April 22, 2023. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services 28 Pa. Code 211.5 (f)(g)(h) Clinical Records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 4 of 4