Health inspection·August 28, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Manual, a review of clinical records, resident observation, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS), for two of 12 residents sampled (Resident 10 and Resident 17).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2024, requires the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A clinical record review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses to include Type 2 diabetes mellitus (body has trouble managing the amount of sugar/glucose in the blood) with diabetic neuropathy (nerve damage due to high blood sugar that lasts a long time), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A clinical record review states Resident 10 had an order for Divalproex tablet, 250 mg three times a day for seizure disorder (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness) as a coded disease state.A clinical record review of the Medication Administration Record (MAR) dated August 2025 verified Resident 10 had received Divalproex tablet, delayed release 250 mg three times a day. A clinical record review revealed Resident 10 received care at an acute care facility from November 24, 2023, to November 28, 2023. The reason for admission and acute care included seizure disorder according to clinical records from the acute care provider. Discharge instructions to the skilled nursing facility dated November 28, 2023, included a medication list which included Divalproex Sodium 250 mg po (by mouth) three times a day. A clinical record review revealed Resident 10 had a care plan (last reviewed July 23, 2025), addressing Seizure Disorder. A clinical records review by the Psychiatric Mental Health Nurse Practitioner on May 29, 2025, noted Resident 10 received Divalproex 250mg for seizures. A quarterly MDS, section I (section intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nurse monitoring, or risk of death) dated August 5, 2025, revealed Resident 10 did not have seizures indicated as a disease diagnosis. An interview on August 28, 2025, at 1:15 PM with the NHA and Employee 3 revealed the MDS did not accurately reflect Resident 10's diagnosis of seizure disorder. A clinical record review revealed Resident 17 was admitted to the facility on [DATE], with diagnoses to include nonrheumatic aortic (valve) stenosis (narrowing of the aortic valve, which restricts the flow of blood from the heart to the rest of the body) and cellulitis of left lower limb (spreading skin infection, most commonly of the lower leg and caused by bacteria entering through a break in the skin). Review of Resident 17's quarterly MDS revealed the assessment reference date (ARD the date that all the information in the MDS assessment is based on. It sets the time period the facility looks at when reporting a resident's health, abilities, behaviors, and needs. The facility must complete the MDS within a certain number of days after the ARD to meet federal requirements.) was May 14, 2025. The MDS completion date (Z0500B) was May 29, 2025, fifteen days after the ARD date. According to the RAI Manual (2024), the MDS completion date must be no later than 14 calendar days after the ARD (ARD + 14 calendar days). Interview on August 27, 2025, at 1:15 PM with the NHA and Employee 3 licensed practical nurse (LPN) revealed the MDS was not completed within the required time frame. A review of the above information was conducted with the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 2 of 8 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 08/28/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Director of Nursing and NHA on August 27, 2025, at approximately 11:00 AM. The facility was unable to produce documentation to support incorrect MDS coding for Resident 10 and Resident 17. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.5(f)(iv) Medical records. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 3 of 8 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 08/28/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement appropriate nursing practices for the administration of an intravenous (IV) medication via central venous catheter for one of 12 residents reviewed (Resident 44).Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) require the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, 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. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Chapter 21.145 b. IV therapy curriculum requirements:(f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under S 21.145 a (relating to prohibited acts), and only under supervision as required under paragraph (1).(1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as aCRNP, physician, physician assistant, podiatrist or dentist).(g) An LPN who has met the education and training requirements of S 21.145 b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under S 21.145 and only under supervision as required under subsection (f): (1) Adjustment of the flow rate on IV infusions. (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions. (3) Administration of IV fluids and medications. (4) Observation of the IV insertion site and performance of insertion site care. (5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes. (6) Discontinuance of a medication or fluid infusion, including infusion devices. (7) Conversion of a continuous infusion to an intermittent infusion. (8) Insertion or removal of a peripheral short catheter. (9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders. (10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route. (11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system. (12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions. (13) Collection of blood specimens from an IV access device. A review of a facility policy titled ‘General Dose Preparation and Medication Administration', last reviewed by the facility on November 15, 2024, revealed the facility is to comply with all applicable laws when administering medications. Clinical record review revealed that Resident 44 was admitted to the facility on [DATE], with diagnosis to include sepsis (serious condition in which the body responds improperly to an infection), Methicillin resistant Staphylococcus aureus (MRSA) infection (type of bacteria resistant to many antibiotics, commonly causing skin infections but can also lead to serious health issues), and Pseudomonas aeruginosa (type of bacteria that can cause infections in the blood, lungs, and other parts of the body). Resident 44 was admitted to the facility with a PICC line (a peripherally inserted central catheter, a long catheter Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 4 of 8 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 08/28/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete introduced through a vein in the arm and passed through to the larger veins into the heart). Physician orders dated August 19, 2025, revealed an order to administer Cefepime (antibiotic medication) 2 gram intravenously (IV) every 12 hours through the PICC line for treatment of Pseudomonas infection through September 21, 2025. Review of the Medication Administration Record (MAR) revealed that between August 19 and August 27, 2025, Employee 1 LPN and Employee 2 LPN documented administration of IV Cefepime to Resident 44 through the PICC line. The facility could not produce any documentation verifying that Employee 1 and Employee 2 had completed the IV therapy education and training required under S21.145(b). There was no evidence of current competency validation, supervision documentation, or internal training specific to PICC line administration. During an interview conducted on August 27, 2025, at approximately 1:45 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility had no documentation of required IV therapy education or competency for either LPN regarding administration of medications through PICC lines. The interview on August 27, 2025, also revealed the facility did not maintain a policy specific to PICC line medication administration and no documented competencies existed for RNs or LPNs regarding safe administration through PICC lines. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services. Event ID: Facility ID: 395644 If continuation sheet Page 5 of 8 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 08/28/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's written facility assessment, staff interviews, professional standards, and facility documentation, it was determined the facility failed to conduct and document a comprehensive, evidence-based facility assessment to ensure licensed nursing staff possessed the required training and competencies necessary to provide care and services for residents requiring intravenous (IV) therapy through peripherally inserted central catheters (PICCs) or other central venous access devices. Findings include:Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Continued review revealed, The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served.The facility assessment dated [DATE], and provided during survey on August 27, 2025, identified that the facility provided specialized services for residents with PICC lines (a long, thin, flexible tube inserted into a vein in the arm and advanced to larger veins near the heart for long-term intravenous therapy) including administration of intravenous medications and routine PICC line care.The facility could not provide documented evidence that licensed nursing staff received initial or ongoing training or competency evaluations (the ability of staff to demonstrate, through education and skills validation, that they can safely and effectively perform specific clinical procedures) in accessing and administering medications through central venous access devices, as required by professional standards and the facility's own assessment.There was no documented policy or procedure in place to guide licensed nursing staff in the safe care and management of central venous access devices, including medication administration, dressing changes, or infection prevention measures.The Director of Nursing (DON) confirmed during an interview on August 27, 2025, that the facility did not have a contract with advanced PICC services, had no established training program for PICC line care, and could not provide documentation of staff competencies specific to PICC line management.The facility failed to ensure its facility assessment was operationalized through staff training, competency evaluation, and implementation of policies and procedures related to intravenous therapy via central venous access devices. As a result, the facility could not demonstrate that licensed nursing staff had the knowledge and skills necessary to provide safe care consistent with regulatory requirements and professional standards of practice. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19 (6)(7) Personnel records. 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2) Management. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services. Event ID: Facility ID: 395644 If continuation sheet Page 6 of 8 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 08/28/2025 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. 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, facility policies and procedures, and staff interviews it was determined the facility failed to develop, implement, and maintain an effective training program for licensed nursing staff (Employees 1 and 2) to care for a resident with a peripherally inserted central catheter (PICC) and ensure staff possessed the skills and competencies necessary for one resident out of twelve residents reviewed (Resident 44).Findings included: Federal regulation requires that a facility develop, implement, and maintain an effective training program for all new and existing staff. The facility must use the facility assessment to determine the amount and types of training necessary to ensure staff competencies meet the needs of the residents as identified in their care plans and the facility assessment. Resident 44 was admitted to the facility on [DATE], with diagnoses including sepsis (a severe infection causing widespread inflammation that can lead to tissue damage or organ failure), bacteremia (the presence of bacteria in the bloodstream), pseudomonas aeruginosa infection (a bacterial infection commonly occurring in people with weakened immune systems), and cellulitis (a bacterial skin infection that causes redness, swelling, warmth, and pain). Physician orders dated August 19, 2025, required the administration of the antibiotic cefepime twice daily via a PICC line, with the line flushed with normal saline before and after each dose and weekly dressing changes. A PICC line is a thin, flexible tube inserted into a vein in the arm and advanced toward the heart so that medications can be delivered directly into the bloodstream. A review of Resident 44's August 2025 electronic Medication Administration Record (eMAR commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional), dated August 19 through August 27, 2025, revealed cefepime was administered nineteen times by the facility's licensed nursing staff through the PICC line. Further review of the Medication Administration Record (MAR) showed that on August 22, 2025, at 10:00 AM, Employee 1, a Licensed Practical Nurse (LPN), signed that cefepime was administered through the PICC line as prescribed. Additionally, Employee 2, an LPN, signed the MAR as administering cefepime on five occasions: August 20, 21, 25, 26, and 27, 2025. Review of Employee 1's personnel file revealed a hire date and orientation completion date of June 15, 2024, and an annual licensed nursing competency/skills review completed on June 30, 2025. The file did not contain documented evidence that Employee 1 received mandatory education for PICC line management prior to providing care for residents with PICC lines. Review of Employee 2's personnel file revealed a hire date and orientation completion date of July 1, 2014, and an annual licensed nursing competency/skills review completed on July 15, 2025. The file did not contain documented evidence that Employee 2 received mandatory education for PICC line management prior to providing care for residents with PICC lines. The facility's annual competency/skills review for licensed nurses did not include training related to PICC line care. During an interview on August 27, 2025, at 1:45 PM, the Director of Nursing (DON) was asked to provide training and competency records for licensed nursing staff who provided care to residents with PICC lines. The DON was unable to provide records through the conclusion of the survey on August 28, 2025. During a follow-up interview on August 28, 2025, at 11:00 AM, the DON and the Nursing Home Administrator (NHA) confirmed the facility had not developed or implemented a training program for PICC line care for licensed nurses and had not included PICC line management in annual licensed nursing competency/skills reviews. The NHA and DON further confirmed the facility should have developed, implemented, and maintained an effective training program, including topics such as PICC line management, based on the resident population and the facility assessment, prior to licensed nursing staff providing care for residents Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 7 of 8 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 08/28/2025 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 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete with PICC lines, and reviewed this training on an annual basis. Pennsylvania State Board of Nursing regulations (Title 49, Chapter 21) require that Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) performing intravenous therapy, including PICC line care, complete a board-approved education program, receive supervised clinical instruction, and undergo ongoing competency assessments. LPNs may perform only those intravenous therapy functions for which they have documented knowledge, skills, and abilities under appropriate supervision. The facility did not provide documentation to demonstrate compliance with these requirements before licensed nursing staff accessed and administered IV medications through the PICC line. The facility failed to use its facility assessment to determine training needs and did not develop, implement, or maintain an effective training program to ensure licensed nursing staff possessed the skills and competencies required for PICC line care. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services. Event ID: Facility ID: 395644 If continuation sheet Page 8 of 8