Inspection·December 20, 2024

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the clinical record revealed Resident 16 was admitted to the facility on [DATE], with diagnoses to include bipolar disorder (a mental health condition that causes extreme mood swings. These include emotional highs, also known as mania or hypomania, and lows, also known as depression). Review of Resident 16's annual MDS assessment dated [DATE], indicated the resident was cognitively intact with a BIMS score of 14. A review of the clinical record revealed Resident 19 was admitted to the facility on [DATE], and has diagnoses to include depression. Review of Resident 19's quarterly MDS assessment dated [DATE], indicated the resident was cognitively intact with a BIMS score of 15. A review of the clinical record revealed that Resident 13 was admitted to the facility on [DATE], and has diagnoses to include alcohol dependence and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Review of Resident 13's quarterly MDS assessment dated [DATE], indicated the resident was mildly cognitively impaired with a BIMS score of 12. Further review conducted during the survey ending December 20, 2024, revealed the resident's activity preferences had not been reviewed since June of 2023. Review of the facility's Activity Calendars for October 2024, November 2024 and December 2024, and through survey ending December 20, 2024, indicated the scheduled activities provided did not offer variety and include programming designed for the younger residents. Interview with the activity director on December 18, 2024, at 10:00 a.m., revealed there are no specific activities for the younger population and no activities directed towards the mental health needs of residents. The facility failed to develop and implement a program of activities to meet the varied preferences, interests and cognitive and functional abilities and needs of the resident population, including offering activities designed for higher functioning younger residents. Refer F838 28 Pa. Code 201.29 (a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395929 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 395929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility investigative reports, and staff interview, it was determined the facility failed to implement effective interventions, including staff supervision, to promote resident safety and prevent repeated falls for one resident (Resident 52) and further failed to implement effective interventions to prevent a fall for one resident (Resident 49) of four sampled residents and failed to maintain a safe environment in one of 3 resident shower rooms on the third floor. Findings include: A review of the clinical record revealed that Resident 52 was admitted to the facility on [DATE], with diagnoses to include Huntington's disease (an inherited condition that affects brain cells and causes physical and emotional changes that get worse over time). A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 9, 2024, indicated the resident exhibited a severe cognitive impairment with a BIMS score of 7 (Brief Interview for Mental Status - a tool to assess cognitive function; a score of 0-7 indicates severe cognitive impairment) and required extensive staff assistance for mobility, transfers, and toileting. Review of the Resident's Fall Risk Evaluation dated September 20, 2024, revealed the resident was at risk for falls related to a history of three or more falls, decreased muscular coordination, and being chair bound. Review of the resident's care plan initially dated July 22, 2021, indicated the resident was at risk for falls due to gait/balance problems, Huntington's disease, and impulsive behavior. Planned interventions to keep the resident free of injury were to anticipate and meet the resident's needs, be sure call light is within reach, ensure wearing appropriate footwear, and every 15-minute safety checks. Review of an investigative report provided by the facility, dated October 9, 2024, at 10:04 PM revealed the resident's alarm sounded, and the resident was found in between the Broda chair (reclining padded wheelchair) and the roommate's wheelchair. A quarter sized area of redness was noted on the resident's left forehead. As a result of the fall the resident was placed in front of the nurses' station for close observation. Review of an investigative report provided by the facility dated October 28, 2024, at 6:30 PM revealed staff heard a bang in the resident's bathroom, entered the room, and observed the resident on her right side on the floor in the bathroom. No injuries were noted at this time. Planned new interventions included to monitor the resident frequently for safety purposes, monitor at nurses' station, and check and change/toilet frequently. Review of an investigative report provided by the facility dated December 1, 2024, at 11:15 AM revealed staff found the resident on the floor close to the bathroom door sitting upright. No injuries were noted at this time. The resident was placed in her recliner chair at the nurses' station. Review of an investigative report provided by the facility dated December 4, 2024, at 8:30 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395929 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 395929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed another resident who was visiting the resident's roommate alerted staff that Resident 52 had fallen backwards on to the floor and hit her head on the bedside table. No visible injuries were noted at the time. The immediate intervention was to remove the bedside table out of the resident's room due to safety hazard. Despite the resident's severe cognitive impairment and poor safety awareness, the facility failed to demonstrate the provision of sufficient staff supervision and appropriate interventions, at the level and frequency required to prevent repeated falls. The facility planned approaches, such as using a call light, relied on the resident's cognitive abilities, which were not consistent with the resident's documented impairment level. The facility could not provide documented evidence of adequate supervision or effective interventions to prevent the resident's repeated falls. Interview with the Nursing Home Administrator (NHA) on December 20, 2024, at 9:00 AM failed to provide documented evidence that the facility provided sufficient supervision and effective safety measures for Resident 52 to prevent repeated falls. A review of the clinical record revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) and CVA (cardiovascular accident -stroke). A quarterly MDS dated [DATE], indicated the resident exhibited moderate cognitive impairment with a BIMS score of 9 (a score of 8-12 indicates moderate cognitive impairment) and was dependent on staff for wheelchair mobility. Review of a facility investigative report dated December 4, 2024, at 6:15 PM revealed the resident was in the dining room, stood up from wheelchair, and when attempting to sit back down the wheelchair rolled away from the resident. The resident landed on his back, striking his head against the base of the fish tank. The resident was assessed and found to have no immediate injuries. An anti-roll back device was applied to wheelchair as an intervention. Further review of the investigation revealed staff failed to ensure the wheelchair locks were engaged when positioning the resident at the dining room table. This oversight directly contributed to the resident's fall. Interview with the director of rehab on December 20, 2024, at approximately 10:30 AM confirmed the resident's wheelchair locks should have been engaged by staff when staff positioned the resident at the dining room table prior to the fall to prevent the wheelchair from rolling. Interview with the Nursing Home Administrator on December 20, 2024, at approximately 11:00 AM failed to provide documented evidence that measures were taken to ensure the locks were engaged prior to the incident. The facility failed to ensure the safety of Residents 52 and 49 by not implementing and maintaining effective fall prevention measures, including proper supervision and equipment use which increased the risk of injury and compromised resident safety. Clinical record review revealed that Resident 41 was admitted to the facility on [DATE] with diagnosis to include Bipolar disorder ( formerly called manic depression, is a mental health condition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395929 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 395929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976 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 0689 that causes extreme mood swings) Level of Harm - Minimal harm or potential for actual harm A review of a care plan dated March 25, 2024 revealed the resident sometimes refuses showers on the scheduled days of the week and scheduled times. Also the care plan noted she may shower independently and shower on other days and times not scheduled. There were no noted interventions regarding showering independently. Residents Affected - Some On December 18, 2024, at 2:36 A.M., a nurse's note indicated Resident 41 requested assistance in setting up the shower room so she could shower independently. Nursing staff honored the request. After the shower, Resident 41 emerged yelling that she had been burned by the water. She reported letting the water run for two minutes before entering, initially finding it at an appropriate temperature. However, during the shower, the water temperature fluctuated unexpectedly between hot and cold. She stated that at one point, the water became boiling, causing burns on the right lateral lower leg and the top of her right foot. Nursing staff assessed the resident but observed no redness, warmth, or blistering. Ice was provided, and Tylenol was administered for reported pain. No water temperatures were recorded at the time of the incident. At 8:10 A.M. on December 18, 2024, facility maintenance tested the water temperature on the third floor at 5:50 A.M. and found it to be within normal limits. Nursing staff completed an every two-hour skin assessment protocol for 24 hours, and no evidence of burns, blisters, or increased redness was noted to Resident 41. The survey team was informed of the incident December 18, 2024, at 9 A.M. An investigation was initiated, and water temperatures were measured in all facility shower rooms. On the second floor, three showers and sinks were within acceptable ranges. On the third floor, two out of three showers and sinks also had temperatures within normal limits, but the shower room near room [ROOM NUMBER] showed elevated water temperatures. Resident room sink temperatures on second and third floors were within normal ranges. During an interview at approximately 11:00 A.M., the maintenance director acknowledged an issue with one of the facility's boilers, which according to the plumber, could not be repaired for several days. The shower room in question was closed until repairs were completed. On December 19, 2024, at 10:00 A.M., Residents 78 and 48, who are cognitively intact, reported that they shower independently. They described staff assistance as limited to providing supplies, such as towels and clothing, and stated that staff did not remain in the shower room or check water temperatures before they began. Both residents noted that water temperatures would initially be comfortable but could become hot during the shower. Interviews revealed no evidence that staff checked water temperatures before resident showers. The Nursing Home Administrator confirmed at 10:30 A.M. on December 18, 2024, that the third-floor shower room's water temperature was inconsistent. She also confirmed that water temperatures were not measured at the time of the incident. During an interview December 18, 2024 at 10:15 A.M., Employee 2 (agency NA) stated that prior to a resident shower, she will put her hand under the running shower water to feel if it is comfortable. She confirmed that she does not take a water temperature prior to a resident shower. She further confirmed that if a resident is independent for showering, her assistance was limited to providing their belongings and leaving the shower room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395929 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 395929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976 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 0689 Level of Harm - Minimal harm or potential for actual harm On December 20, 2024, at 10:00 A.M., the Director of Nursing could not confirm how many residents were classified as independent shiverers. He acknowledged that no assessments had been conducted to evaluate whether these residents could safely shower independently and could not define the criteria for independent showering. Residents Affected - Some 28 Pa. Code 201.18 (b)(1)(e)(1) Management. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395929 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 395929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility's accounts payable ledger and staff interviews, it was determined the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. Findings include: The 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, revealed a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident's health and safety are jeopardized. A review of the current outstanding accounts payable ledger revealed outstanding balances as of December 20, 2024, for greater than 121 days beyond terms of payment which include: Allstate Pest Management: $1,969.48 Commonwealth of Pennsylvania: $16,000.00 Concept Medical: $2,681.31 E. Copier Solutions: $1,372.66 [NAME] Medical Center: $2,576.65 General Healthcare Resources: $19,771.26 Geri Medix: $7,539.46 HD Supply Facilities Maintenance: $1,337.37 Integrated Medical Group LLC: $1,850.00 [NAME] Valley Hospital: $3,395.75 National Care Systems LLC: $2,520.00 Nutro Co: $24,324.00 [NAME] Elevator: $4,243.42 Respiratory Care Practices Inc.: $6,060.90 [NAME] J. Thurick, DO: $1,850.00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395929 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 395929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976 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 0836 Schuylkill Plus!: $2,435.00 Level of Harm - Minimal harm or potential for actual harm SEIU Healthcare PA Health and Welfare Plan: $172.35 SEIU Union Dues: $1,835.55 Residents Affected - Some SEIU Training Fund: $19,525.02 Select Ambulance: $25,393.95 [NAME] RX: $1,197.86 Total Plan Concepts: $226,751.24 West Mahanoy Township Tax Collector: $71,758.10 [NAME] Foods: $11,779.43 Selective Insurance: $6,472.00 Advanced Audiology: $3,800.00 During an interview on December 19, 2024, at 12 PM, the Nursing Home Administrator confirmed that the facility owners had not provided evidence of payments or payment agreements for the outstanding invoices. She also stated that facility administration did not have access to billing or payment records and could not verify whether the listed bills had been paid. This failure to ensure timely payment of essential goods and services demonstrates non-compliance with Federal, State and Local Laws), which requires facilities to pay bills in a timely manner to prevent jeopardizing the health and safety of residents. 28 Pa. Code 201.14(g) Responsibility of Licensee. 28 Pa. Code 201.18 (b)(3)(e)(1)(2) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395929 If continuation sheet Page 8 of 8