Health inspection·June 9, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to administer supplemental oxygen consistent with professional standards of practice for one of two residents reviewed (Resident 75) and failed to store supplemental oxygen equipment per professional standards of practice for one of two residents reviewed (Resident 19). Residents Affected - Few Findings include: A review of the policy titled Oxygen Administration, last reviewed without changes on May 22, 2023, revealed that when oxygen tubing is not in use, store the tubing in a plastic bag (with a zip-lock top that is obtained from the storage room). The policy further noted to place the bag containing the tubing on top of the machine, making sure the tubing does not drag on the floor. A review of the current physician orders for Resident 19 dated April 7, 2023, instructed staff to apply oxygen at two liters per minute via nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose) at all times. Review of Resident 19's current care plan revealed that the resident receives supplemental oxygen related to the medical history. Observation of Resident 19's room on June 7, 2023, at 11:03 AM revealed the resident was out of the room. Nasal cannula tubing was observed attached to an oxygen concentrator (a medical device that concentrates oxygen from the ambient air). The remaining end of the tubing was observed in a partially open dresser drawer. The tubing was unbagged and unprotected from contamination. Observation of Resident 19 on June 8, 2023, at 10:30 AM revealed the resident was sitting at her bedside table and receiving oxygen via a nasal cannula. The resident's wheelchair was also present near the foot of the bed and had a second nasal cannula attached to a portable oxygen unit. The second nasal cannula was draped across the back of the wheelchair, unbagged, and unprotected from contamination. A concurrent interview with Employee 7, nurse aide, revealed Employee 7 was unaware how the resident's extra nasal cannula should be stored and stated the LPNs (licensed practical nurses) oversee a resident's oxygen therapy. An interview with the Nursing Home Administrator on June 8, 2023, at 10:38 AM revealed the oxygen tubing should be placed in a protective bag when not in use. Observation of Resident 19's room on June 8, 2023, at 1:30 PM revealed the resident was out of the room. A nasal cannula was observed attached to an oxygen concentrator that was turned on. The remaining tubing was draped across the resident's bed. The tubing was unbagged and unprotected from contamination. The above information regarding Resident 19 was reviewed in a meeting on June 8, 2023, at 2:00 PM with the Nursing Home Administrator and Director of Nursing. Review of a physician's order for Resident 75 dated March 20, 2023, revealed the resident was to receive oxygen at one liter per minute via nasal cannula as needed with exertion, and the staff may titrate (the process of determining the amount of oxygen based on the blood oxygen saturation) the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 2 of 9 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 395787 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Haven, Inc 4702 East Main Street Belleville, PA 17004 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 0695 Level of Harm - Minimal harm or potential for actual harm oxygen to keep the pulse oximetry (a device placed on a finger to monitor of a person's blood oxygen saturation) greater than 90%. The resident may be on room air (no oxygen) when at rest. Review of the oxygen saturation summary for Resident 75 revealed that the last pulse oximetry was measured on May 19, 2023, at 3:45 PM and determined to be 95% on oxygen. Residents Affected - Few Observation of Resident 75 on June 6, 2023, at 12:50 PM revealed the resident was sitting in the dining room eating lunch and had oxygen running at one liter per minute by way of nasal cannula. Clinical record review for Resident 75 revealed a pulmonary (relating to the lungs, organs for breathing) consultation under the miscellaneous section of the electronic medical record. Review of this attachment revealed a form entitled Physician Progress Notes/Consultation Form from pulmonary that was not dated. Further review revealed two entries that indicated the resident did not need oxygen at rest and the resident needs to use a flutter device (a respiratory device to help people clear secretions from their lungs) four times daily, 10 puffs each time. This form was not a complete consultation. During a meeting with the Nursing Home Administrator and Director of Nursing on June 8, 2023, at 1:30 PM the surveyor requested the complete pulmonary consultation as it was not available in the electronic or paper medical record. Review of the pulmonary consultation for Resident 75 dated March 16, 2023, indicated the resident had stable pulmonary nodules (a small mass on the lung), chronic mycobacterium avium intracellular (infection caused by a group of bacteria in the lungs), and chronic bronchitis/bronchiolitis (inflammation/infection of the large and small airways in the lungs). The pulmonary consultation recommended oxygen with ambulation and sleep at two liters per minute and oxygen was not needed at rest. During an interview with Employee 1 (infection preventionist) on June 9, 2023, at 8:50 AM the surveyor discussed that the pulmonary consultation was not present in Resident 75's medical record until asked for by the surveyor, and the oxygen rate as currently ordered at one liter per minute to keep the pulse oximetry above 90% did not reflect the pulmonary consultation. Resident 75 did not have her pulse oximetry measured since May 19, 2023. Nursing documentation for Resident 75 dated June 9, 2023, at 9:04 AM revealed that the nurse reviewed the oxygen order from pulmonology with the attending physician and the oxygen order was changed to two liters at all times and the resident preferred this rate. During a further interview with Employee 1, on June 9, 2023, at 9:20 AM it was confirmed that she discussed the consultation findings with the attending physician and confirmed that Resident 75 should be receiving oxygen at two liters per minute. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 3 of 9 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 395787 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Haven, Inc 4702 East Main Street Belleville, PA 17004 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on staff interviews and review of facility documentation, it was determined that the facility failed to ensure that nurse aides received an annual performance review for two of three nurse aides reviewed (Employees 2 and 3). Residents Affected - Few Findings Include: Review of the facility's list of active nurse aide staff revealed Employee 2 had a hire date of November 1, 2021. Employee 2 should have had an annual performance review by November 1, 2022. Employee 3 had a hire date of November 30, 2016. Employee 3 should have had an annual performance review by November 30, 2022. Requests to review Employees 2 and 3's performance reviews revealed no documented evidence that the facility completed the reviews at least once every 12 months. Interview with the Nursing Home Administrator on June 8, 2023, at 11:30 AM confirmed the above findings. 28 Pa. Code 201.19 Personnel policies and procedures FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 4 of 9 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 395787 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Haven, Inc 4702 East Main Street Belleville, PA 17004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a safe and sanitary condition in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen on June 6, 2023, between 10:28 AM and 10:57 AM with Employee 5, Director of Dining Services, revealed the following: A large stain on the ceiling above a stainless-steel prep table holding various appliances. The prep table had a cobweb between the bottom shelf and one of the legs. A significant amount of debris on the floor along the wall of the walk-in freezer that included a discarded small ice cream container. A significant accumulation of a black colored substance on a vent above the dishwasher that extended into the ceiling. An air conditioner in the dishwasher area had a significant accumulation of dust build-up on all vents and the surrounding perimeter of the air conditioner. A large black colored corner fan in the dishwasher area had a significant build-up of dust on the fan blades and guards. Brown colored stains were observed on the wall above the fire extinguisher in the dishwasher area. The window screens above the three-compartment sink had a significant build-up of dust and debris. The windowsill had an accumulation of dust and debris that included a large strand of hair. A rack that held what Employee 5 identified as clean dishes included four plastic organizers that held multiple cups. There was a significant accumulation of a flaking, unidentified substance on the organizers. The rack also held multiple black trays that contained various types of dishes. There was an accumulation of dust and debris that included hairs in the bottom of the trays. A rack that held two plastic organizers that contained personal sized boxes of cereal had a build-up of a flaking, unidentified substance and dust on the organizers. The receiving area and dry goods storage area for the main kitchen had a significant build-up of dust on an air vent located in the ceiling. There were eight ceiling tiles with large, brown-colored stains. Employee 5 reported a pipe broke a couple weeks ago. During operation of the dishwashing unit, a valve on the top of the dishwasher expelled a large volume of water that accumulated on the top of the dishwashing unit. Employee 5 reported the machine was not to discharge water from the valve during operation and was unable to advise how long the dishwasher valve was leaking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 5 of 9 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 395787 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Haven, Inc 4702 East Main Street Belleville, PA 17004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A subsequent observation of the dishwasher on June 6, 2023, at 12:45 PM revealed that unidentified staff were using the dishwasher to clean dishes from the lunch service. The valve on top of the dishwasher continued to leak. Staff members were unable to identify how long the dishwasher had been leaking from the valve. A review of the temperature log for the dishwasher revealed that the temperature should be measured by staff three times a day before using the machine (at breakfast, lunch, and dinner). The recommended wash cycle temperature was listed as 150 to 165 degrees Fahrenheit. The document indicated to contact the supervisor immediately if the temperatures are not correct. Review of the most recent facility documentation revealed various staff had documented the following wash temperatures below the recommended values: May 27, 2023: breakfast 140 degrees; lunch 144 degrees May 28, 2023: breakfast 142 degrees; lunch 146 degrees; dinner 145 degrees May 29, 2023: breakfast 145 degrees May 30, 2023: breakfast 140 degrees; lunch 140 degrees; dinner 148 degrees May 31, 2023: breakfast 145 degrees June 1, 2023: breakfast 140 degrees; lunch 148 degrees June 2, 2023: breakfast 149 degrees June 3, 2023, breakfast 145 degrees June 4, 2023: breakfast 140 degrees There was no evidence of any corrective action taken by staff and Employee 5 revealed that he was not aware that staff were documenting the wash temperatures below the recommended values for the dates reviewed. The above findings were reviewed in a meeting on June 8, 2023, at 2:00 PM with the Nursing Home Administrator and Director of Nursing. 483.60 Food Procure, Store/Prepare/Serve - Sanitary Previously cited 06/17/2022 28 Pa. Code 211.6 (c) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 6 of 9 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 395787 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Haven, Inc 4702 East Main Street Belleville, PA 17004 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage. Residents Affected - Many Findings include: Observation of the facility's main dumpster on June 6, 2023, at 10:58 AM revealed multiple pieces of broken glass, a discarded clear glove, and several small pieces of paper products on the ground surrounding the dumpster. The surveyor reviewed the above findings with Employee 5, Director of Dining Services, at the time of the findings. The above findings were also reviewed in an interview on June 8, 2023, at 2:00 PM with the Nursing Home Administrator and Director of Nursing. 28 Pa. Code: 201.18 (b)(3) Management 28 Pa. Code 207.2 (a) Administrator's responsibility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 7 of 9 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 395787 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Haven, Inc 4702 East Main Street Belleville, PA 17004 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on select review of policies and staff interview, it was determined that the facility failed to develop and implement an effective Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia). Residents Affected - Some Findings include: Review of Department of Health and Human services, Centers for Medicare and Medicaid services (CMS) memo Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated July 6, 2018, revealed, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC toolkit. Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Maintains compliance with other applicable Federal, State, and local requirements. Interview with the Administrator on June 8, 2023, at 10:43 AM initially revealed that the facility did not have a water management program. At a subsequent interview with the Administrator on June 8, 2023, at 1:08 PM the surveyor was provided with a multi-page CDC toolkit entitled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. The Administrator indicated that the facility was following the information in the guide for water management. Review of the guide entitled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, dated June 24, 2021, Version 1.1, indicates that the following steps should be implemented to have an effective water management program. Step 1, Establish a water management team Step 2, Describe the building water systems using text and flow diagrams Step 3, Identify areas where Legionella could grow and spread Step 4, Decide where control measures should be applied and how to monitor them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 8 of 9 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 395787 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Haven, Inc 4702 East Main Street Belleville, PA 17004 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 0880 Step 5, Establish ways to intervene when control limits are not met Level of Harm - Minimal harm or potential for actual harm Step 6, Make sure the program is running as designed and is effective Step 7, Document and communicate all the activities. Residents Affected - Some Interview with Employee 4, maintenance, on June 8, 2023, at 1:48 PM revealed that the facility has not completed any of the above steps for developing a water management program, including identifying areas where Legionella could grow, implementing control measures, and ensuring that the program is effective. Employee 4 also indicated that no documentation could be provided to indicate a program was established. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 9 of 9