Inspection·February 28, 2025

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feeling tired, initiated on July 22, 2024. Interventions in place included decreasing environmental stimulation at night and evaluating for reasons sleep is not being obtained, such as grief, noise, pain, disease management, and disease diagnoses. The care plan indicated Resident 196 has a communication problem related to usually understanding and being understood initiated on July 25, 2024. Interventions in place include providing a safe environment with call light in reach, the bed in the lowest position, and avoiding isolation. A care plan indicated Resident 196 has a behavior problem related to suicidal ideation initiated on September 21, 2024. Interventions include calling external behavior health services as needed, 15-minute checks when in bed, and allowing the resident to lie on fall mats for safety when threatening to throw themselves on the ground. A clinical record review revealed a progress note dated October 27, 2024, at 12:28 AM, indicating the resident was found on the floor near her bed. The note indicated the resident was assessed without injury and transferred to the nursing station for observation and safety. The note indicated that Resident 196 requested to return to bed but continued under observation for safety reasons. A progress note dated October 27, 2024, at 3:38 AM, indicated the resident was returned to bed at approximately 1:00 AM but attempted to roll out of bed. The resident was brought out to the nurse's station in her wheelchair, where she ate pudding, and watched videos. Resident 196 requested to be put back in bed, stating, I don't want those pillows suffocating me. Resident 196 was offered a mattress on the floor in the common area, where she appeared comfortable. Resident assessed with vital signs within normal limits. A review of a witness statement dated November 4, 2024, revealed Employee 1, Registered Nurse's (RN), description of events that occurred on October 27, 2024, indicated Resident 196 was unwilling to remain in her bed. Resident 196 continually attempted to stand and slide from her wheelchair despite being offered snacks, toileted, diverted with videos, covered with warm linens, or engaged in conversation. Employee 1, RN, placed Resident 196's mattress and safety mats directly on the floor in the common area. Employee 1, RN, indicated she utilized available furniture to surround Resident 196 while she was positioned on the mats and mattress to create an adult-sized playpen. Employee 1, RN, indicated that after a while, Resident 196 stated, I don't like it in here, and Get me out of the cellar. Employee 1, RN, indicated she directed staff to remove Resident 196 from the playpen and return her to her wheelchair. A review of a witness statement dated November 4, 2024, revealed Employee 2, Licensed Practical Nurse (LPN), indicated that on October 27, 2024, Employee 1, RN, placed furniture around Resident 196 to make a playpen around the resident. Employee 2, LPN, indicated that Employee 1, RN, brought the bed out into the dayroom, placed the resident on the bed, and surrounded the bed with furniture to keep Resident 196 safe. Employee 2, LPN, explained that the resident attempted to get off the mattress, and additional mats were placed near the resident. Employee 2, LPN, confirmed that furniture was placed around Resident 196 to prevent her from moving. Employee 2, LPN, expressed concern regarding this intervention but did not report taking further action. A witness statement from Employee 3, Nurse Aide (NA), described the placement of furniture around Resident 196 as abusive and confirmed the resident remained surrounded by furniture for at least one hour before being removed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 2 of 15 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 02/28/2025 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 196's clinical record revealed no physician's orders or documented evidence that a licensed provider authorized the use of surrounding furniture as a restraint to ensure her safety. Additionally, there was no documented evidence that other less restrictive measures were attempted and failed prior to the use of this restraint method. Further, there was no evidence that the resident or the resident's representative consented to the intervention or documented evidence that Employee 1, RN, attempted to call the external behavioral health service with concerns regarding the resident's safety. During an interview on February 27, 2025, approximately 12:30 PM, Employee 3, Nurse Aide (NA), indicated that on October 27, 2024, she recalled that Resident 196 was not herself. Employee 3, NA, indicated that Resident 196 was more active than usual, attempting to get out of bed and out of her chair. Employee 3, NA, indicated she remembered the resident's bed and chair alarm went off frequently that night. Employee 3, NA, indicated she observed Resident 196 in the dayroom surrounded by furniture but did not see who placed the furniture around the resident. Employee 3, NA, estimated the resident was surrounded by furniture for about an hour but was uncertain of the exact duration. Employee 3, NA, explained that Resident 196 would not have been able to remove the furniture without staff assistance. Employee 1, RN, and Employee 2, LPN, were not available for interview in person or by telephone interview. During an interview conducted on February 28, 2025, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed there was no documented physician order, care plan intervention, or resident or resident representative consent for the use of surrounding furniture as a safety intervention. The DON and NHA acknowledged the facility failed to ensure that Resident 196 was free from physical restraints not required to treat a medical symptom and that all appropriate interventions should have been exhausted before considering a restraint. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 3 of 15 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 02/28/2025 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 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 a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 13 sampled. (Residents 4). Residents Affected - Few Findings included: A review of Resident 4's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). A review of the resident's Pennsylvania Preadmission Screening Resident Review Identification (PASRR) Level 1 form dated October 4, 2016, revealed the resident had a positive screen for serious mental illness and requires a further Level II evaluation. A review of a letter from the Pennsylvania Department of Human Services Office of Mental Health and Substance Abuse Services dated October 6, 2025, revealed the resident had been determined eligible for Level II services and the facility must provide or arrange for provision of mental health services. A review of Resident 4's significant change MDS assessment dated [DATE], revealed in Section A 1500 Preadmission Screening and Resident Review (PASRR) the resident was not considered a state Level II PASRR to have a serious mental illness. An interview with the RNAC (registered nurse assessment coordinator) on February 27, 2025, at 12:40 PM, confirmed the aforementioned MDS Assessment was inaccurate. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 4 of 15 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 02/28/2025 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of residents as expressed by three out of four residents interviewed during a resident group interview. (Residents 4, 6, and 8). Residents Affected - Some Findings include: A review of Resident Council meeting minutes dated January 16, 2025, revealed residents in attendance expressed concerns about decreased activity staff. The minutes indicated this concern was previously addressed by the Nursing Home Administrator (NHA). A review of Resident Council meeting minutes dated February 21, 2025, revealed residents in attendance expressed a desire to lead Bingo activities one day each week. A clinical record review revealed Resident 4 was admitted to the facility on [DATE]. A review of a change in status Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 17, 2025, revealed that Resident 4 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review revealed Resident 6 was admitted to the facility on [DATE]. A review of a quarterly MDS assessment dated [DATE], Section C1000. Cognitive Skills for Daily Decision Making revealed that Resident 6 has moderate impairment in her ability to make decisions regarding tasks of daily life. The assessment indicated the resident was not able to complete the Brief Interview for Mental Status (BIMS). A clinical record review revealed Resident 8 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 8 is cognitively intact with a BIMS score of 15 indicating intact cognition. During a resident group interview on February 26, 2025, at 10:00 AM, three out of four residents in attendance raised concerns indicating there were no staff available to facilitate programs or activities on Sundays or Mondays. Resident 4 stated that she would prefer at least one program on Sundays and Mondays and expressed an interest in hymn singing on Sundays. Residents 6 and 8 also indicated there is very little to do on Sundays and Mondays. Both residents indicated an interest in an additional bingo activity. Resident 8 stated she would be interested in leading an activity for other residents on days when no activity staff were available. Resident 6 stated that she does not socialize or spend time in the activity room when no staff are present to facilitate activities. Residents 4, 6, and 8 confirmed they had brought up the concern about the lack of activities on Sundays and Mondays during Resident Council meetings, but no action had been taken to resolve the issue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 5 of 15 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 02/28/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm A review of the resident activity calendar for February 2025 confirmed that no staff-facilitated activities were scheduled on Sundays or Mondays from February 1, 2025, through February 28, 2025. A review of facility staffing documentation confirmed that no activity staff were assigned to work on Sundays or Mondays from February 1, 2025, through February 28, 2025. Residents Affected - Some During an interview with the Nursing Home Administrator (NHA) on February 27, 2025, at approximately 1:00 PM, the NHA confirmed that no activity staff were assigned to work on Sundays or Mondays. The NHA also confirmed that residents had raised concerns during Resident Council meetings and that the facility was in the process of assigning activity staff to address residents' interests, needs, and preferences. The NHA acknowledged that it is the facility's responsibility to ensure that residents are provided with an ongoing program of activities designed to meet their needs, interests, and preferences. 28 Pa. Code 201.29 (a) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 6 of 15 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 02/28/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to monitor the nutritional parameters of two residents (Resident 36 and Resident 20) with an identified significant weight loss and failed to implement a planned nutrition intervention in response to weight loss for one resident (Resident 20) out of 13 residents sampled. Residents Affected - Some Findings include: A review of a facility policy titled Monitoring Resident's Weight last reviewed by the facility on December 14, 2024, revealed if a resident experiences a weight loss or gain, the resident will be reweighed at the time of the noted change in weight. If there is a weight change a physician will be notified. Further the policy indicated if there is a five-pound weight gain or loss, the resident will be reweighed at the time of the noted change in weight. If there is a gain/loss it will be documented, and the physician and the Food Service Supervisor will be notified. A review of the clinical record revealed that Resident 36 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction due to unspecified occlusion or stenosis of the right MCA (a type of stroke in the middle cerebral artery that occurs when blood flow to the brain is blocked), dysarthria (a speech disorder that makes it hard to speak clearly), and hemiplegia affecting the left dominant side (the left side of the body including the arm, leg, and face are paralyzed). A review of Resident 36's clinical record noted the following weights: December 8, 2024 - 174.0 lbs. December 17, 2024 - 161.6 lbs. indicating a 12.4 lb. weight loss which was a 7.12% weight loss in 9 days. Further review of the resident's clinical record revealed the following weights: February 9, 2025- 157.2 lbs. February 24, 2025 - 150.2 lbs. indicating a 7 lb. weight loss. There was no documented evidence the facility conducted a required reweight at the time of the weight loss, as outlined in the facility's policy. Additionally, there was no documentation the physician and resident representative were notified of the weight loss. Interview with the Director of Nursing on February 27, 2025, at approximately 10:00 AM confirmed that the resident's reweights were not conducted as per facility's policy when a change in weight was documented, and the weight loss was not communicated to the physician each time a significant weight loss was noticed. Review of the clinical record revealed that Resident 20 was admitted to the facility on [DATE], with diagnoses which include dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 7 of 15 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 02/28/2025 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 0692 A review of the resident's weight record revealed the following recorded weights: Level of Harm - Minimal harm or potential for actual harm September 20, 2024- 255.6 lbs. October 3, 2024- 245.6 lbs. Residents Affected - Some November 1, 2024- 235.2 lbs. November 2, 2024- 234 lbs. December 11, 2024- 232 lbs. January 8, 2025- 226 lbs. February 5, 2025- 217.6 lbs. (reflective of a 38 lb.,14.8% significant weight loss since September 20, 2024) February 19, 2025- 221 lbs. The facility failed to reweigh the resident following the significant weight loss documented on February 5, 2025, and there was no documented evidence that the physician and resident representative were notified. A review of a dietary weight change note written by the registered dietitian on February 14, 2025, indicated that a dietary referral had been made in response to a 37.9-pound weight loss over five months. The resident's current weight was 217.6 pounds, with a body mass index (BMI screening tool calculation that estimates body fat based on weight and height) of 31.2, which falls within the overweight category, despite the significant weight loss. The dietitian recommended daily weights to monitor further changes. The resident's appetite was noted to vary, and the resident was receiving a no concentrated sweets (NCS), no added salt (NAS) regular diet with fortified foods at all meals to support nutritional intake. Additionally, the resident's protein powder supplement was increased from one scoop to three times daily to provide additional protein. The note also referenced a fluid restriction of 1800 cc due to congestive heart failure (a chronic condition in which the heart cannot pump enough blood to meet the body's needs) and edema (swelling caused by excess fluid buildup in the body's tissues). To further support caloric intake, the dietitian recommended adding a daily health shake, a nutritional beverage supplement that provides additional calories, protein, and essential nutrients. However, a review of the clinical record revealed discrepancies as the resident's fluid restriction had been discontinued on October 1, 2024, yet it was still referenced in the dietary note. There was no documented evidence that daily weights were being completed as recommended and there was no documented evidence the recommended health shake was implemented as part of the resident's nutritional intervention. Interview with the director of nursing (DON) on February 28, 2025, at approximately 11:00 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 8 of 15 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 02/28/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm confirmed that the resident's reweight was not conducted as per facility's policy when a change in weight was documented, and the weight loss was not communicated to the physician and resident representative at the time the significant weight loss was noticed. The DON confirmed that Resident 20's fluid restriction was discontinued, daily weights were not being completed, and that the health shake which was recommended as a nutritional intervention was not implemented. Residents Affected - Some 28 Pa Code 211.5(f)(ii)(ix) Medical records 28 Pa Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 9 of 15 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 02/28/2025 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide person-centered care as prescribed to meet the current clinical needs, and failed to follow physician orders for management of a PICC line for one of 13 residents sampled (Resident 94). Residents Affected - Few Findings include: Review of the facility Flushing Central Vascular Access Devices (CVAD- also known as a central line or central venous catheter is a thin flexible tube that is inserted into a vein to deliver fluids, medication, and other therapies into the bloodstream) and Midline Catheters (thin flexible tube that is inserted into a vein in the upper arm to deliver fluids and medications into the bloodstream)last reviewed December 14, 2024, indicated that Central Venous Access Devices and midline catheters will be flushed and aspirated for a blood return prior to each infusion to assess catheter function and after each infusion to clear the infused medication/solution from the catheter lumen, to decrease the risk of contact between incompatible medication/solutions, and to prevent complications. A physician order is required and should include type, amount, and frequency of flush. Review of the clinical record revealed that Resident 94 was admitted to the facility on [DATE], with a PICC line (a long tubing introduced through a vein in the arm, then through the subclavian vein into the superior vena cava or right atrium of the heart to administer parenteral fluids and medication) in the upper left arm for antibiotic therapy and had diagnoses to include right total knee replacement (TKR) and left knee infection. A physician order dated February 6, 2025, noted an order for Vancomycin HCL (an antibiotic) 1.5 gm intravenous (within a vein) one time daily for left knee infection until March 13, 2025. A physician order dated February 6, 2025, noted an order for Cefazolin Sodium (an antibiotic) 2 gm intravenous three times per day for right TKR until March 13, 2025. A physician order dated February 5, 2025, noted an order for Normal Saline flush 0.9% use 10 ml intravenously every shift for medications before and after IV (intravenous- within a vein) antibiotic administration. Review of Resident 94's February 2025 Medication Administration Record (MAR) failed to indicate the Resident's PICC line was flushed before and after the administration of each IV antibiotic as per physician order and facility policy. Interview with the Director of Nursing on February 28, 2025, at approximately 11:30 AM confirmed that there was no documented evidence that Resident 94's PICC line was consistently flushed before and after use for medication administration in accordance with physician orders and facility policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 10 of 15 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 02/28/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 select facility policy, observation, and staff interview, it was determined the facility failed to maintain respiratory equipment in a manner to promote optimal functioning for one resident out of 13 sampled residents. (Resident 24). Residents Affected - Few Findings include: A review of facility policy entitled Oxygen Therapy Mask and Nasal Cannula; Nebulizer Treatments last reviewed on December 14, 2024, revealed oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties Additionally, the policy states that oxygen tubing and humidifier bottles are to be changed weekly. A review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively). A review of the resident's clinical record revealed a physician's order dated January 16, 2025, and discontinued on January 23, 2025, for oxygen at 2 liters per minute via nasal cannula (a device that delivers extra oxygen through a tube into the nose) as needed for shortness of breath. A current physician's order dated January 24, 2025, was noted for oxygen at 1 liter per minute via nasal cannula as needed for shortness of breath. An observation on February 25, 2025, at approximately 11:00 AM revealed an oxygen concentrator in the resident's room. The oxygen tubing attached to the machine was dated January 20, 2025. An observation on February 26, 2025, at 11:45 AM, revealed the oxygen tubing remained attached to the oxygen concentrator and dated January 20,2025. An observation on February 27, 2025, at 9:20 AM revealed the oxygen tubing remained attached to the resident's oxygen concentrator dated January 10, 2025. An interview with the Director of Nursing on February 27, 2025, at 9:28 AM revealed the oxygen tubing should be changed weekly, and the DON acknowledged the oxygen tubing for Resident 24 had not been replaced per facility policy and confirmed the facility's failure to maintain the resident's oxygen equipment. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 11 of 15 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 02/28/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide pharmaceutical services to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate accounting of controlled drugs when acquiring, receiving, dispensing, and or administering to identify possible diversion for one of three residents reviewed (Resident 43). Findings include: Review of the facility's Disposition of Controlled Medications Policy last reviewed December 14, 2024, indicated all controlled medication will be disposed of in accordance with federal and state laws and regulations. To prevent unauthorized/potential misappropriation of property, all controlled medications will be disposed of in a timely manner. Controlled medications must be accounted for, inventoried, and destroyed in the presence of two licensed clinicians. The disposition is documented on the accountability record to include the prescription number of the drug, name of the drug, and dosage of the drug, the quantity of the drug being disposed, method of disposal, and the signature of the clinicians present. Review of Resident 43's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included diabetes and prostate cancer (cancer that develops in the prostate gland, which is part of the male reproductive system). A physician's order dated November 14, 2024, noted an order for Oxycodone (opioid analgesic pain medication, a controlled medication) 2.5 mg every 2 hours as needed for pain or dyspnea. (difficult breathing). Nursing documentation dated November 27, 2024, revealed Resident 43 was discharged to home with discharge instructions and medications. Review of Resident 43's signed discharge instructions indicated the resident was discharged home with medications which included a total of 10 Oxycodone 2.5 mg tablets. Further review Resident 43's closed record revealed no documented evidence of a controlled medication accountability record for the Oxycodone 2.5 mg tablets. Interview with the director of nursing (DON) on February 28, 2025, at 10:00 AM failed to provide documented evidence that Resident 43's controlled medication accountability record for the Oxycodone 2.5 mg tablets was completed per facility policy. The DON confirmed that a controlled medication accountability record is to be completed for all controlled medications to prevent unauthorized or potential misappropriation of property and ensure accurate accounting and disposition of controlled drugs. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 12 of 15 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 02/28/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined the physician failed to act upon pharmacist identified irregularities in the medication regimen of three of 13 residents sampled (Resident 11, 24, and 4). Findings include: A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], and had diagnoses that included anxiety disorder, major depressive disorder (condition characterized by persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life), and dementia (disorder characterized by a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving) Medication regimen reviews were conducted on October 10, 2024, November 11, 2024, December 10, 2024, and February 2, 2025, indicating the pharmacist made recommendations. However, the facility was unable to provide documentation of the recommendations or the physician's response to the recommendations. A review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia and major depressive disorder. Medication regimen reviews conducted on July 23, 2024, and September 20, 2024, indicated that the pharmacist made recommendations. The facility could not provide documentation of the recommendations or the physician's response to the recommendations. A review of Resident 4's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and major depressive disorder. Medication regimen reviews conducted on September 20, 2024, and October 10, 2024, indicated that the pharmacist made recommendations. However, the facility was unable to provide documentation of the recommendations or the physician's response to the recommendations. In an interview with the Nursing Home Administrator on February 28, 2025, at approximately 1:00 PM, the administrator confirmed that the facility could not locate documentation of the pharmacist's recommendations and confirmed there was no documentation the physician had acted upon the pharmacist recommendations. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 13 of 15 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 02/28/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined the facility failed to ensure the presence of physician documentation of the clinical rationale for the increase of an antipsychotic medication for one resident out of five sampled residents for unnecessary medication use. (Resident 2). Findings included: Clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that include psychotic disorder (a mental health condition that causes a significant loss of touch with reality) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 15, 2024, revealed that Resident 2 is severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 01-07 indicates severe cognitive impairment). Additionally, a care plan for impaired cognitive function related to dementia, initiated on March 30, 2020, included interventions such as encouraging engagement in activities, promoting movement within the facility, and ensuring consistent caregivers whenever possible. A care plan indicating Resident 2 has the potential to be physically aggressive related to anger and dementia was initiated on September 20, 2021, with interventions including medication administration as ordered, behavioral analysis, psychiatric consultation as needed, and redirection from distressing stimuli. Additionally, a care plan for impaired cognitive function related to dementia, initiated on March 30, 2020, included interventions such as encouraging engagement in activities, self-propelling in facility hallways and activity rooms, and providing consistent caregivers as much as possible. A progress note dated January 27, 2025, at 1:25 PM, documented that a psychiatric interdisciplinary team meeting was held, where new recommendations were made, and the physician was noted to be aware and in agreement. Subsequently, a new physician order was written to increase Quetiapine Fumarate Oral Tablet 25 MG, directing 12.5 mg (½ tablet) by mouth twice a day, revised from once a day to twice a day. However, further review of the clinical record revealed no documented evidence of the clinical rationale for increasing Resident 2's antipsychotic medication, no discussion of alternative treatment options, and no documentation of resident or resident representative involvement in the decision-making process. A review of medication administration records from January 2025 through February 2025 confirmed that Resident 2 received the additional dose of Quetiapine Fumarate daily from January 28, 2025, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 14 of 15 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 02/28/2025 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 0758 through February 28, 2025 (32 doses administered). Level of Harm - Minimal harm or potential for actual harm During an interview on February 27, 2025, at approximately 1:00 PM, the Director of Nursing (DON) stated they were unable to provide documented evidence of a clinical rationale for the medication increase. The DON confirmed the resident's antipsychotic medication was increased and acknowledged the clinical record lacked documentation supporting the rationale for the dosage increase, alternative interventions considered, or evidence of resident or resident representative participation in the decision-making process. The DON also confirmed it is the facility's responsibility to ensure residents are free from unnecessary psychotropic medication. Residents Affected - Few 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.2 (d)(3)(7)(9) Medical director. 28 Pa. Code 211.5 (f)(ii)(iii)(x) Medical records. 28 Pa. Code 211.12 (d)(3) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396086 If continuation sheet Page 15 of 15