Health inspection·November 9, 2023

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the physician failed to act upon pharmacist identified irregularities in the medication regimen of one out of five residents sampled for unnecessary medications (Resident 3). Findings include: A review of Resident 3's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia, bipolar disorder [is a serious mental illness characterized by extreme mood swings such as extreme excitement episodes or extreme depressive feelings], dysphagia (difficulty swallowing), and Parkinson's disease [is a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement.] A review of a Consultant Report conducted by the facility's consultant pharmacist dated June 30, 2023, revealed that the pharmacist made a recommendation to Resident 3's attending physician to attempt a gradual dose reduction (GDR) on the physician prescribed Zyprexa [s an antipsychotic medication that affects chemicals in the brain. Zyprexa is used to treat psychotic conditions such as schizophrenia and bipolar disorder (manic depression); however, is not approved for use in older adults with dementia] 5 mg daily for bipolar disorder in the presence of dementia. The pharmacist indicated that the resident's most recent GDR attempted was May 2020 and failed in July 2020. The pharmacist recommended an annual attempt at a GDR, or that the physician document clinical contraindication if the medication was to continue at the current dose, and requested that a resident-specific rationale describing why a GDR attempt may be likely to impair function or increase behavior in the resident be completed by the physician. There was no documented evidence that Resident 3's attending physician had acted upon the pharmacist identifed drug irregularity as of the time of the survey ending November 9, 2023. During an interview with the Director of Nursing (DON) on November 8, 2023, at 10:30 AM, confirmed that Resident 3's attending physician failed to respond to the consultant pharmacist's recommendation for an annual GDR or provide clinical justification to continue the current prescribed dose of Zyprexa, an antipsychotic medication. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 2 of 7 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 11/09/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free from unnecessary psychoactive drugs by failing to ensure the presence of clinical rationale for the continued use of an as needed psychotropic medication for one of five residents reviewed (Resident 24). Findings include: Review of Resident 24's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including depression. Review of Resident 24's clinical record revealed a physician's order for Lorazepam (used to treat anxiety) tablet 0.5 MG give 1 tablet by mouth every 6 hours as needed for Anxiety with a start date of October 29, 2023, and an end date of December 27, 2023. Review of the November 2023 Medication Administration Records (MAR) revealed that the medication (Lorazepam) was not administered to the resident during the month of November 2023. Review of the physician's notes for the months of October 2023 and November 2023 revealed that the physician failed to document the clinical rationale for the continued use or identify the need for the extended duration for the prn (as needed) order for the psychoactive drug without re-evaluation of its necessity. An interview was conducted with the Director of Nursing on November 09, 2023, at approximately 12:30 p.m. verified that there was no physician documentation of the clinical rationale for the prn medication to be used more than 14 days. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 3 of 7 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 11/09/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of select facility policies, and staff interview, it was determined that the facility failed to ensure adherence to medication use by/discard dates in one of one medication storage rooms, failed to store drugs a resident's medication in a safe manner, (Resident 236) and failed to ensure accurate receiving and storage of emergency medications. Findings include: Observation of the facility's medication storage room on [DATE], at 10:00 AM revealed stock medication located in a cabinet, one 16 fluid ounce bottle of Liquid Pain Reliever with an expiration date of [DATE], available for resident use. Employee 2, LPN, confirmed that the medication was expired and should have been discarded. In another cabinet in the medication room, five vials of injectable Vitamin B12 (Cobalamin)1000 mcg were observed stored in pill bottle containers with caps. The outside of the plastic pill bottles had remnants of adhesive prescription labels indicating the medication was once prescribed to specific residents, but then stored for future use. An interview with the director of nursing (DON) confirmed that vials of B12 were specifically prescribed to select residents and the remaining vials should have been discarded. An observation of the medication cart on [DATE], accompanied by Employee 1, LPN, at 7:40 AM revealed an unopened vial of Lispro Insulin 100 u in a box labeled by pharmacy stating Refrigerate until opened. The box contained a vial dated as dispensed [DATE]. Interview with Employee 1, LPN, indicated that the insulin should have been refrigerated until opened and not stored in the med care, which was confirmed by interview with Director of Nursing (DON). A review of the facility policy entitled Emergency Medication Supplies-Emergency Kits dated as reviewed by the facility [DATE], indicated that the emergency medication supply or kit should be stored in a known secured location per facility policy, with immediate access only by authorized facility personnel. Only authorized facility staff shall possess keys or codes to unlock the emergency kit. The facility staff breaking the lock or tamper evident seal on the emergency kit should replace the lock with a tamper-evident lock or seal provided by the pharmacy and located in the emergency kit. The facility staff may record the name of the nurse who accessed the emergency kit., the date and the time the emergency kit was accessed, the serial number of the tamper-evident lock or seal replaced on the emergency kit. To indicate the emergency kit was opened by facility staff and replacement of the box or replenishment of removed doses is needed, the tamper-evident lock or seals provided by the pharmacy may be a different color than the original one placed by the pharmacy. The facility should maintain a list of inventory in the emergency kit in a location easily retrievable for quick reference. An observation of the refrigerator located in the medication room on [DATE], at approximately 8 AM revealed two black boxes containing medications for emergency use. Employee 2, LPN, explained the boxes contained medications that required refrigeration for emergency use. One black box was sealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 4 of 7 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 11/09/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm with green zip ties to indicate that it was not accessed and all the contents of the box should reflect the label on the box. One black box dated [DATE], however, was unsecured, and not locked according to emergency drug policy lacking tamper-evident seals. This unsecured box had a label that indicted it contained the following: Residents Affected - Few Novolog Flexpen Insulin Pen 1 x 3ml Novolog 70/30 Flexpen Insulin Pen 1 x 3ml Levemir Flextouch Insulin Pen 1 x 3ml Lantus Solostar Insulin Pen 1 x 3ml Humalog kwikpen Insulin Pen 1 x 3ml Lorazepam 2mg/ml vial 2 x 2ml The label read refrigerate upon arrival and please return old box with driver upon arrival of new box. According the Employee 2, LPN, this box should have been sealed with a red zip tie/seal indicating that it had been opened. When observed, this box had no seal. Observation of the contents of this box, revealed a paper record indicating that on [DATE] one pen of Novolog 70/30 was removed for use. The contents also included one Levimer Flex Pen, one Novolog Flex Pen and one Humalog Kwik Pen, according to the inventory list. However, the inventory list indicated the box should have contained one Lantus Solostar Insulin Pen and two Lorazepam 2 mg/ml vials. Interview with Employee 2, LPN, at that time, revealed that the box should have been sealed and sent back when the second emergency box arrived on [DATE], as per directions on emergency box label and facility policy. Employee 2 and the DON stated during interview on [DATE], that they were unaware of the location of the Lantus Solostar Pen and the two vials of Ativan listed on the inventory list. During continued interview, the DON stated that pharmacy indicated that Ativan would not have been contained in the E-box due ot a shortage of the drug, despite the label on the box noting that it was in the box. The DON stated that nursing staff signs for the emergency box upon delivery to the facility and rely on the pharmacy label to verify its contents. The facility does not verify the contents of the e-box and it could not be determined if the two vials of Ativan and one pen of Lantus Solostar were missing or were not contained in the emergency box provided by pharmacy. The facility policy entitled Delivery and Receipt of Routine Deliveries dated [DATE] indicated that the facility was to exchange all emergency medication kits with the pharmacy driver, but does not included procedures to verify the contents of the boxes, which was confirmed by the Director of Nursing during interview on [DATE]. The facility failed to store and accurately receive medications according to facility policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 5 of 7 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 11/09/2023 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 0761 28 Pa Code 211.9(k)(l)(1) Pharmacy services Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 6 of 7 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 11/09/2023 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 0926 Have policies on smoking. 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 the facility's smoking policy and staff interview, it was determined that the facility failed to implement established procedures to accurately assess residents for safe smoking ability for one resident out of one resident identified as a current smoker (Resident 19). Residents Affected - Few Findings include: A review of the facility's policy entitled Resident Smoking Policy last revised by the facility February 2022, indicated that a smoking assessment would be completed with readmission, quarterly and with any significant change in resident's condition. During entrance conference on December 20, 2022, at 9:30 AM, the Nursing Home Administrator (NHA) provided a list of residents at the facility that currently smoke, which included one resident, Resident 19. Review of Resident 19's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included history of falling, alcohol abuse, and tremors. The most recently completed quarterly smoking assessment was dated May 5, 2023. Further review of the resident's clinical record failed to reveal that a smoking assessment was completed quarterly as indicated in the facility's resident smoking policy. There was no documented evidence that a quarterly resident smoking assessment was completed in August 2023. Interview with the NHA on November 8, 2023, at 1:45 PM, indicated that Resident 19 should have had a more recent quarterly smoking assessment conducted. The NHA confirmed that the facility failed to timely complete a quarterly smoking assessment for Resident 19 to ensure that smoking privileges remains safe and appropriate for the resident. 28 Pa. 209.3 (a)(b) Smoking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 7 of 7