Health inspection·April 14, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding a resident assessment for pressure ulcer concerns for one of 23 residents reviewed (Resident 150). Residents Affected - Few Findings include: Clinical record review for Resident 150 revealed that they were admitted to the facility on [DATE], with a sacral (triangular area at the bottom of the spine) ulcer. Facility staff completed an initial assessment of Resident 150's sacral ulcer with measurements noted as 10 cm (centimeters) long by 8 cm wide by no depth, with red, watery drainage. Staff ordered appropriate treatment. On April 6, 2025, at 3:55 PM staff documented that at 9:30 AM they went to change Resident 150's sacral dressing, however, there was no dressing on the wound. Staff cleansed and applied a new dressing, noting that they observed yellow slough (dead skin) on the wound bed (base of wound) with a slight odor. On April 6, 2025, at 5:40 PM staff documented that they changed Resident 150's sacral dressing at 3:40 PM and noted a change/concern in the wound drainage (now with a tan/gray drainage) and an increase in depth near the top of the wound. Staff measured Resident 150's wound as 7.2 cm (centimeters) long by 5 cm wide by 1.5 cm deep in the center of the wound. At the top of the wound, staff measured a depth of 2.2 cm. Staff notified Employee 1, registered nurse, assistant director of nursing/infection preventionist, of the concern. On April 10, 2025, at 10:33 AM and 10:43 AM (3.75 days later) Employee 1 documented that they assessed Resident 150's sacral ulcer and observed the above noted slough. The slough was able to be moved with bone now visualized at the base of the wound. Employee 1 measured the wound as 7.2 cm long by 5 cm wide and 2.5 cm deep with no undermining or tunneling (wound channeling under tissue) with a mixture of purulent (pus like) and serous (clear) drainage. Employee 1 determined the need to change/update the resident's sacral ulcer dressing order based on their assessment. Employee 1 did not assess Resident 150's sacral wound timely to identify potential wound and dressing changes. The above information was reviewed during an interview on April 15, 2025, at 10:40 AM with the Nursing Home Administrator. 483.25 Quality of Care Previously cited 5/31/24 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 2 of 14 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 04/14/2025 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 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of two residents reviewed (Resident 28). Residents Affected - Few Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 28 revealed the following current physician orders: Oxygen at 2 liters per minute (LPM) via NC (nasal canula, tubing to deliver oxygen to the nose) to keep SpO2 (oxygen saturations) greater than 91 percent as needed Further clinical review for Resident 28 revealed that they last utilized oxygen on March 28, 2025, at 6:02 AM. Observation of Resident 28's room on April 8, 2025, at 11:03 AM, and April 9, 2025, at 10:27 AM revealed that there was an oxygen concentrator beside his bed. Attached to the concentrator there was an undated humidification cannister that had an unbagged, undated nasal cannula tubing attached. The tubing was draped over the concentrator and onto the floor. Concurrent interview with Resident 28 on April 8, 2025, at 11:03 AM revealed that he had not utilized oxygen recently. The above information was reviewed with the Nursing Home Administrator during an interview on April 10, 2025, at 2:10 PM. 28 Pa. Code 211.10 (c)(d) Resident care policies 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 14 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 04/14/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on a review of facility documentation, clinical record review, employee personnel record information, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to medication administration, the care and assessment of residents with indwelling urinary catheters, and gastrostomy tubes for one of five employees reviewed for competencies (Employee 2; Residents 101 and 57). Findings include: The Centers for Medicare and Medicaid Services (CMS) QSO-24-13-NH memo dated June 18, 2024, noted that requirements specify 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. The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess to deliver the necessary care required by the residents being served. The facility assessment reviewed during the onsite survey last updated March 31, 2025, revealed that RN (registered nurse) competency and training would include catheter insertion and flushing (Foley, indwelling urinary catheters, flexible tubing inserted into the bladder to drain urine) and medication administration. The assessment stipulated that the lists were not all inclusive. Although the list of competencies and trainings did not refer to RN care and services for artificial feeding systems, the LPN (licensed practical nurse) competency and training list included enteral feeding (PEG, a flexible tube inserted through the abdominal wall and into the stomach for the purpose of administering nutrition, fluids, and medications) and use of pumps or feeding by gravity. A review of the facility Resident Matrix (CMS-802, form used to identify pertinent care categories for residents who reside in the facility) documentation revealed that the facility had a total of nine residents with indwelling urinary catheters within the 107 resident facility census (8.4 percent). Clinical record review for Resident 101 revealed active physician orders for staff to irrigate a urinary catheter every eight hours as needed for blockages and to change a 16 French (The French scale, also known as the French gauge, is a widely used measurement system for the size of catheters) urinary catheter every 28 days and as needed for occlusion or leakage as needed. Clinical record review for Resident 57 revealed active physician orders to change an indwelling urinary catheter, size 16 or 18 French coude (A coude catheter is a type of urinary catheter that features a curved tip, designed to navigate around obstacles in the urethra, such as an enlarged prostate or strictures), monthly and as needed for occlusion or leakage, and to irrigate the foley catheter with 60 milliliters (ml) of normal saline daily and as needed. Resident 57's active physician orders also instructed staff to flush his PEG tube two times a day with 240 ml of water and to assess his feeding tube placement every shift and with every use. Staff were also to flush the PEG tube as needed with 30 ml of water before and after medication administration with 10 ml between each medication as needed if Resident 57 was unable to take his meds orally. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 4 of 14 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 04/14/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Employee 2's (registered nurse) personnel records revealed that the facility completed new hire orientation training on September 17, 2024. The orientation training list provided did not include evidence of any competencies completed related to indwelling urinary catheters, PEG tubes, or medication administration. Email communication from the Nursing Home Administrator dated April 11, 2025, at 10:35 AM confirmed that the facility had no evidence of Employee 2's competencies. The facility could only provide the RN orientation checklist that did not include the verification of competencies in medication administration, indwelling catheter care, or PEG tube care. 28 Pa Code 201.20(a) Staff development FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 5 of 14 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 04/14/2025 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 27). Residents Affected - Few Findings include: Clinical record review for Resident 27 revealed the facility admitted her on January 8, 2024, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 27's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated December 9, 2024, indicated that the facility assessed Resident 91 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 27's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on April 10, 2025, at 2:00 PM. On April 11, 2025, at 10:23 AM the Nursing Home Administrator confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Resident 27's dementia prior to surveyor's questioning. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 6 of 14 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 04/14/2025 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 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. Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medication for one of five residents reviewed for medication regime concerns (Resident 101). Findings include: Clinical record review for Resident 101 revealed that the facility admitted her on March 14, 2025. An active physician order dated March 14, 2025, instructed staff to administer Lunesta (Eszopiclone, a sedative hypnotic medication used to induce and maintain sleep) 2 mg (milligram) by mouth at bedtime. An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 19, 2025, identified that staff administered a hypnotic medication to Resident 101, and the facility would proceed to a care plan for the psychotropic medication use. Review of care plans developed for Resident 101 did not include the use of a sedative hypnotic for sleep, did not include non-pharmacological interventions used, and did not identify target behaviors that the facility would monitor to support the rationale for the continued use of the medication. Interviews with the Nursing Home Administrator, Director of Nursing, and Employee 1 (assistant director of nursing/infection preventionist) on April 10, 2025, at 2:00 PM and with the Director of Nursing on April 11, 2025, at 9:30 AM confirmed that there was no plan of care or target behaviors identified or monitored for Resident 101's use of the sedative hypnotic. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 7 of 14 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 04/14/2025 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 - Many 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 and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and two of five nursing units (200 and 300). Findings include: An observation in the facility's main kitchen and the downstairs pantry and cold storage areas on April 8, 2025, at 10:09 AM with Employee 3, Assistant Director of Nutritional Services, revealed the following: The fryer had a moderate amount of black grease build up in the grease trap. Clean pans were stored on top of the oven where there was a considerable amount of dust buildup. The food warmer was observed with dried brown spills/splatters on the interior base of the warmer and on three sheet trays that were holding pans of food inside the warmer. A windowsill in the dishwashing area was caked with white debris. The entire window was coated in a white substance. A box of hamburger patties was observed on a shelf in the walk-in freezer. The box was open, and a bag of hamburger patties was open to air inside the box. A box of chicken breasts was also observed open beside the box of hamburger patties, with a wide open bag of chicken sitting in the box exposed to air. Food debris was observed under the shelving units in the walk-in freezer. A piece of the metal wall covering on the interior back corner of the walk-in cooler was hanging off the wall. A stack of clean dish washing racks was observed next to a shelving unit holding clean dishware. The racks contained pieces of dried food/debris built up in corners/indentations of the racks in several spots. An ice scoop was observed sitting directly on top of the ice machine uncovered. The flooring under the ice machine contained dust and debris. The downstairs dry storage was observed to have several brown stained ceiling tiles and dried liquid inside a ceiling light cover. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on April 10, 2025, at 2:25 PM. An observation of the 200-unit nourishment room refrigerator on April 9, 2025, at 10:05 AM revealed a shelf full of individual containers of juices in a variety of flavors such as apple, grape, and cranberry stored in the refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 8 of 14 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 04/14/2025 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 There was no evidence to indicate when the juices were placed there, when they needed to be used by, or a manufacturer's expiration date on the containers. A concurrent observation of the 300-unit nourishment area refrigerator also revealed a shelf full of the same kind of juices stocked in the refrigerator. Residents Affected - Many An interview with Employee 3 on April 9, 2025, at 10:05 AM revealed the juices are delivered to the facility frozen, and dietary staff pull the boxes from the freezer to thaw. Employee 3 indicated the staff date the box of juice when they pull it from the freezer, but once the containers are taken out of the box, such as for storing in the refrigerators on the nursing units, they would not be dated. Observation of a case/box of the individual juices with Employee 3 on April 9, 2025, at 12:05 PM revealed manufacturer instructions on the box indicating the product was to be used within 14 days once thawed. There was no evidence to indicate when the juices stored on the nursing units referenced above were pulled from the freezer, thawed, or when the 14-day expiration would occur. The above information regarding the juices was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on April 11, 2025, at 2:35 PM. 483.60(i)(2) Store, prepare, food safe and sanitary Previously cited 5/31/24 28 Pa. Code 201.14 (a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 9 of 14 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 04/14/2025 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 review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions for one of 22 residents reviewed (Resident 101), implement appropriate transmission based precautions (TBP) for one of one resident reviewed on TBP (Resident 96), and ensure an environment free from the potential spread of infection with the storage of resident supplies on one of five nursing units (200; Residents 62 and 77). Residents Affected - Some Findings include: The facility policy entitled Isolation, Transmission Based Precautions, last reviewed without changes on May 22, 2024, revealed standard precautions will be used when caring for residents. Transmission based precautions will be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. If a resident is suspected of, or identified as having a communicable infectious disease, the registered nurse supervisor will notify the infection control designee and the resident's physician for appropriate transmission-based precautions. Transmission based precautions will remain in effect until the physician or infection control designee discontinues them. Contact precautions will be used in addition to Standard Precautions for residents with specific infections that can be transmitted by direct and indirect contact. Clinical record review for Resident 96 revealed the facility admitted him on October 21, 2024. Review of Resident 96's physician orders revealed an order dated April 7, 2025, for contact isolation due to a shingles rash on his face and neck. Nursing documentation dated April 8, 2025, at 5:15 AM revealed Resident 96 began on the medication Valtrex (an antiviral medication) related to his diagnosis of shingles. Documentation revealed a pustule rash continues on Resident 96's face, and down the right side of his neck with pustules remaining intact. Contact precautions remain in place. When the rash is still blistered and contains fluid in the blisters, the person is considered contagious if the rash comes in close contact to someone else, so it is best to keep the rash covered. Observation of Resident 96 on April 8, 2025, at 10:12 AM revealed he was in the dining/activity room seated at a table with 11 other residents making Easter eggs. The shingles rash was observed on his face and neck. The shingles rash on Resident 96's neck was exposed with pustules. Resident 96's rash was not covered. Observation of Resident 96 on April 9, 2025, at 10:25 AM revealed he was walking on the unit holding hands with another resident (Resident 96's wife). The shingles rash on Resident 96's neck was again exposed with pustules. Resident 96's rash was not covered. Observation of Resident 96 on April 9, 2025, at 12:29 PM he was in the dining room eating lunch, with two other residents seated at his table. Resident 96 was unable to be interviewed regarding any education he received regarding his rash and contact precautions due to his current cognitive status. Interview with Employee 1, infection control nurse, on April 10, 2025, at 2 PM confirmed these findings. She stated that staff should have covered Resident 96's rash on his neck with the exposed pustules. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 10 of 14 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 04/14/2025 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 Level of Harm - Minimal harm or potential for actual harm An observation of Resident 62's bathroom on April 8, 2025, revealed a bag of bladder pads stored directly on the floor beside the toilet. An observation of Resident 77's bathroom on April 8, 2025, revealed a plastic bag of maxi pads stored directly on the floor beside the resident's toilet. Residents Affected - Some The above information regarding Residents 62 and 77 was reviewed with the Nursing Home Administrator and Director of Nursing on April 10. 2025, at 2:30 PM. Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, Enhanced Barrier Precautions in Nursing Homes, dated March 20, 2024, revealed that CMS was issuing new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. In 2019, CDC (Centers for Disease Control) introduced a new approach to the use of personal protective equipment (PPE) called Enhanced Barrier Precautions (EBP). In July 2022, the CDC released updated EBP recommendations for Implementation of PPE Use in nursing homes to prevent spread of MDROs. The CDC's, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), stipulated that, When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Nursing care facilities are to use enhanced barrier precautions (EBP, gown and glove use) for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of CDC guidance at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revealed that signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure precautions are followed. CDC has created examples of signs that can be used by facilities to communicate information about Transmission-Based and Enhanced Barrier Precautions. Facilities can use these signs or modify them to create signs that work for their facility. Review of CDC guidance at https://www.cdc.gov/long-term-care-facilities/media/pdfs/Observations-Tool-for-Enhanced-Barrier-Precautions-Implementat Enhanced Barrier Precautions (EBP) Implementation-Observations Tool (For use in Skilled Nursing Facilities/Nursing Homes only) reiterated that signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. The EBP sign should also include a list of the high-contact resident care activities for which PPE (gown and gloves) should be worn. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure EBP are followed. Signs should not include information about a resident's diagnosis or the reason for the use of EBP (e.g., presence of a resistant germ, wound). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 11 of 14 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 04/14/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the CDC sign for EBP revealed that the first directive is that everyone must clean their hands, including before entering and when leaving the room. Review of the facility's policy entitled, Enhanced Barrier Precautions, last reviewed without changes May 22, 2024, revealed that the compliance guidelines included that the facility would have the discretion on how to communicate to staff which residents require the use of EBP. The implementation of EBP included to make gowns and gloves available near or outside the resident's room, ensure alcohol-based hand rub is in every resident room, position a trash can and linen cart inside the resident room near the exit, the infection preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education, and provide education to residents and visitors. The facility policy did not include the implementation of the placement of signage visible to individuals entering the room to signal the specific actions they should take to protect themselves and the resident. Clinical record review for Resident 101 revealed a physician's order dated March 28, 2025, for staff to implement enhanced barrier precautions related to an indwelling urinary catheter (flexible tubing inserted into the bladder to drain urine). Observation of Resident 101's room on April 9, 2025, at 10:18 AM revealed that her door was partially shut. There was no signage or indication before entering her room of the implementation of enhanced barrier precautions. Interview with Employee 2 (registered nurse) on April 9, 2025, at 10:33 AM revealed that the sign that indicated Resident 101 required EBP was positioned on the inside of Resident 101's door and was not visible to any person before entering her room. The interview confirmed that the sign positioned on the inside of Resident 101's door was the CDC Enhanced Barrier Precautions sign that included the directive that, Everyone must clean their hands, including before entering and when leaving the room. Interview with the Nursing Home Administrator on April 10, 2025, at 10:00 AM confirmed that the facility's EBP policy did not include the necessity of signage to notify staff and/or visitors that EBP were necessary. Interview with the Nursing Home Administrator and the Director of Nursing on April 10, 2025, at 10:35 AM confirmed that the facility policy did not include an expectation that staff would post a sign visible to individuals entering the room to signal the specific EBP actions they should take to protect themselves and the resident. The interview also confirmed that the facility policy did not include how the facility would provide education to residents and visitors regarding EBP requirements. The interview indicated that generally Employee 1 (assistant director of nursing/infection preventionist) ensures that a sign is posted. The Director of Nursing stated that she believed that current nationally accepted standard guidance regarding EBP did not require the use of a sign. The surveyor referred the Director of Nursing and the Nursing Home Administrator to the CDC and CMS guidance noted above. 28 Pa. Code 211.10(d) Resident care policies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 12 of 14 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 04/14/2025 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 28 Pa. Code 211.12(d)(1) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 13 of 14 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 04/14/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for one of five residents reviewed for immunizations (Resident 4). Residents Affected - Few Findings include: The policy entitled Pneumococcal Vaccination of Residents, last reviewed without changes May 22, 2024, revealed all residents of the facility and/or admissions to the facility will be offered the pneumococcal immunization. The resident and/or representative will receive information regarding the types of vaccinations available, and the benefits and potential side effects of the vaccine. Each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated or if they have already been immunized. Each resident's pneumococcal immunization status will be determined upon admission, or soon afterwards, and will be documented on the pneumococcal consent form and in the resident's medical record. The immunization/vaccine will be administered according to the standing physician order as per CDC (Centers for Disease Control) recommendations. Clinical record review revealed the facility admitted Resident 4 on February 1, 2022. Documentation in Resident 4's clinical record revealed she received two pneumococcal vaccines (Pneumovax 23 and Prevnar 13) prior to her admission in 2022. According to the CDC guidance entitled Pneumococcal Vaccine Timing for Adults dated October 2024, Resident 4's pneumococcal vaccinations would not be completed until she received a Prevnar 20 or Prevnar 21 at least five years after the last pneumococcal vaccine dose. There was no documented evidence to indicate that the facility offered Resident 4 an updated pneumococcal vaccination. Interview with Employee 1, infection control preventionist, on April 11, 2025, at 10:05 AM confirmed the above findings for Resident 4. Employee 1 stated at the time of sending Prevnar 20 consents (January 2024) Resident 4 was not yet eligible. Employee 1 indicated when Resident 4 became eligible the facility missed obtaining a consent and offering her the updated pneumococcal vaccination. Employee 1 contacted Resident 4's family and they indicated that they would like her to receive the vaccination. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395787 If continuation sheet Page 14 of 14