Health inspection·December 27, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bring her a drink but staff failed to bring her a drink as requested approximately 2-hours earilier. The resident stated, I'm at the mercy of staff to do things that I can't do for myself and it's frustrating when it takes them hours to come in and care for you. A review of Resident 1's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included arthritis, malnutrition, and a history of cancer. The resident was cognitively intact and dependent for transfers and toileting. Interview with Resident 1 on December 27, 2023, at approximately 10:45 AM, revealed that this morning at 6:00 AM she was incontinent of BM (bowel movement) and pressed her call bell for staff to change her soiled brief. The resident stated that she waited until 6:50 AM (50-minutes later) for staff to provide her incontinence care. The resident stated that she was upset that she had to sit in feces for that length of time and didn't want it {feces} to soil her blankets. A review of clinical record revealed Resident 6 was admitted to the facility on [DATE], with diagnosis to include cerebral infarction (stroke), Cauda Equina Syndrome (extreme pressure and swelling of the nerves at the bottom of the spinal cord which cuts off sensation and movement to the lower body and can affect control of the bladder and bowel) and retention of urine (Urinary retention is when you can't empty your bladder completely or at all). A review of Resident 6's care plan, dated December 16, 2023, revealed that the resident had functional bladder incontinence due to impaired mobility and Cauda Equina Syndrome with a planned intervention for staff to straight catheterize the resident every 6 hours (tube inserted into the bladder to drain the urine). Interview with Resident 6 on December 27, 2023, at approximately 12:00 PM, revealed that he has waited 30 minutes or more for staff to answer his call bell when he requests assistance. He expressed concern that since he is unable to empty his bladder on his own due to his medical condition and requires nursing staff to perform a straight catheterization, he has experienced uncomfortable abdominal pressure and pain waiting for staff to respond to his call bell when he needs to be catheterized. He reported that nursing staff perform the straight catheterization every six hours as ordered but sometimes he needs it more frequently, especially at night. He stated that the extended wait times generally occurred during the middle of the night or early morning shifts. A review of clinical records revealed Resident 8 was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke). Interview with Resident 8 on December 27, 2023, at 12:30 PM revealed that he feels that short staffing is a problem in the facility because he waits up to 45 minutes to an hour for staff to answer his call bell. The resident stated that staff have told him you have to wait in line, we're short staffed and that there have been times he has soiled himself while waiting for staff to answer his call bell when he needs toileting assistance. Interview on December 27, 2023, at approximately 2:15 PM with the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified that it is the expectation that all residents be treated with dignity and respect. The DON was unable to explain why multiple residents are reporting untimely staff response to their requests for assistance and staff's failure to provide needed care and services in a timely manner, which was negatively affecting the residents' quality of life in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 2 of 3 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 396086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Skilled Nursing and Rehabilitation Ce 1 Matthew Drive Pottsville, PA 17901 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 0550 28 Pa. Code 201.18 (e)(1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12 (d)(5) Nursing Services 28 Pa. Code 201.29 (a) Resident rights Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 3 of 3