Pennsylvania Department of Health
BUFFALO VALLEY LUTHERAN VILLAGE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BUFFALO VALLEY LUTHERAN VILLAGE
Inspection Results For:

There are 105 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


BUFFALO VALLEY LUTHERAN VILLAGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and an Abbreviated Survey to investigate one Complaint, completed on August 27, 2026, it was determined that Buffalo Valley Lutheran Village was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations: Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician appropriately addressed pharmacy recommendations for three of five residents reviewed for unnecessary medications (Residents 17, 40, and 69). Findings include: The facility policy entitled "Drug Regimen Review," last reviewed without changes April 10, 2026, revealed that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The licensed pharmacist will report in writing any irregularities to the attending physician, the facility's medical director, and the Director of Nursing to be acted upon. Irregularities will be documented on a separate, written report and sent to the physician, medical director, and Director of Nursing, listing the resident's name, relevant drug and irregularity the pharmacist has identified. The physician will document in the resident record that the identified irregularity has been reviewed, and any action taken to address it. If the physician chooses not to act upon the pharmacy consultant recommendations, the physician must document rationale as to why the change is not indicated in the resident record. All medication regimen review documents will be maintained in the resident medical record Clinical record review for Resident 40 revealed a consultant pharmacist review dated July 17, 2026, noting Resident 40 has a diagnosis of dementia and receives Quetiapine (an antipsychotic medication) 50 milligrams (mg) in the morning and 100 mg at bedtime. Resident 40's physician requested the facility attempt a gradual dose reduction of Resident 40's Quetiapine or document a rationale for declining. Resident 40's physician accepted the consultant pharmacist recommendation (undated) and outlined a four-week plan to decrease Resident 40's Quetiapine. An unidentified person wrote "family is refusing due to maintaining quality of life." This statement wasn't signed or dated. Further review of Resident 40's clinical record revealed the facility did not attempt a gradual dose reduction of Resident 40's Quetiapine as agreed to by Resident 40's physician. Clinical record review for Resident 17 revealed a consultant pharmacist recommendation dated May 2, 2026, noting Resident 17 is 98 years old and may benefit from de-prescribing. The consultant pharmacist recommended considering discontinuing Resident 17's Rosuvastatin (medication used to lower cholesterol and reduce the risk of heart disease, heart attack, and stroke) and Calcitonin nasal spray. There was no response from Resident 17's physician. A staff identified by the Nursing Home Administrator as a nurse wrote (undated) "per doctor XXX no changes at this time." The above findings for Residents 40 and 17 were reviewed with the Nursing Home Administrator on August 26, 2026, at 2:20 PM. Clinical record review for Resident 69 revealed consultant pharmacist report dated November 13, 2025, which indicated that a medication regimen review was performed and recommended a GDR (gradual dose reduction) for Resident 69's Quetiapine (a type of antipsychotic medication) 12.5 milligram dose. The physician response indicated they were declining the recommendation because the family does not want it changed. The physician did not provide any clinical basis for this decision. Clinical record review for Resident 69 revealed consultant pharmacist report dated February 26, 2026, which indicated that a medication regimen review was performed and recommended a GDR for Resident 69's Quetiapine 12.5 milligram dose. The physician response indicated they were declining the recommendation because the family wishes it to stay the same. The physician did not provide any clinical basis for this decision. The surveyor requested any further documentation available related to Resident 69's GDR on August 25, 2026, at 2:30 PM during a meeting with the Nursing Home Administrator and Employee 5, registered nurse. No further information indicating the physician decision to continue Resident 69's antipsychotic medication was provided. The above findings regarding Resident 69's consultant pharmacist reports were reviewed with the Nursing Home Administrator on August 27, 2026, at 10:30 AM. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Plan of Correction - To be completed: 10/12/2026

1. Residents 40 and 69 will be reviewed at the next facility Gradual Dose Reduction meeting for potential dose reduction recommendations. Resident 17 will have recommendations for de-prescribing resent to physician for consideration with request for documentation if a GDR is not recommended per their medical opinion/expertise.

2. The unit manager or designee will audit psychoactive medication pharmacy recommendations for the month of August to ensure they have been properly reviewed and documented on to include rationale if the GDR is not medically appropriate.

3. The Nursing Home Administrator will educate Family Practice Center physicians and CRNP that provide services in the facility on regulation and appropriate response to recommendations when not proceeding to follow pharmacy recommendations.

4. The UM or designee will audit 10 recommendations monthly x 3 months for timeliness and appropriateness of responses when pharmacy recommendations will not be followed. Tracking and trending will be reviewed through the Quality

Assurance performance Improvement Committee for review and recommendations.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations: Based on a review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to complete required background check screening for one of five newly hired employees reviewed (Employee 2) and failed to train a new employee on abuse for one of five newly hired employees reviewed (Employee 1). Findings include: The facility policy entitled "Abuse Prevention Program- Pennsylvania Only," last reviewed without changes April 10, 2026, revealed all employees and volunteers shall receive training on abuse, neglect, and misappropriation of resident property upon hire, and annually. A criminal record check is conducted on all candidates for employment pursuant to PA (Pennsylvania). In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police (PSP) background check within 30 days of hire on all prospective employees. If the applicant has not been a Pennsylvania resident for the two years before application, they will need to have a PSP criminal history background check completed and a Federal Bureau of Investigation (FBI) Background Check. Review of Employee 2's (laundry) personnel record revealed the facility hired her on May 11, 2026. Employee 2 did not attest to living in Pennsylvania for two years prior to her hire and the facility was unable to provide evidence that a FBI background check was completed. Interview with the Nursing Home Administrator on August 27, 2026, at 11:38 AM confirmed the above findings for Employee 2. Review of Employee 1's (dining services associate) personnel record revealed the facility hired her on June 24, 2026. Further review of Employee 1's personnel file revealed the facility did not train Employee 1 on abuse at the time of her hire. Employee 1 received training on abuse and neglect on July 24, 2026. Interview with Employee 3 (human resources) on August 27, 2026, at 9:12 AM confirmed the above findings for Employee 1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.19(1)(10) Personnel policies and procedures

Plan of Correction - To be completed: 10/12/2026

1. Employee 1 completed abuse training on 7/24/2026. Employee 2 started the federal background check process on 8/26/2026.

2. The Nursing Home Administrator or designee will audit all newly hired employees in the past 30 days, personnel records to ensure federal background checks for those employees not residing in the state for 2 consecutive years were done per regulations and Abuse training was completed within 7 days of their hire date.

3. The Nursing Home Administrator, or designee will educate the hiring managers on the regulations regarding federal background checks and abuse training requirements.

4 The Nursing Home Administrator or designee will audit 10 new hire files monthly x 3 months for timely abuse training and completion of federal background checks per regulations. Tracking and trending will be reviewed through the Quality Assurance performance Improvement Committee for review and recommendations.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) REQUIREMENT Discharge Process:

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations: Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and residents' representative received written notice of transfer and written notice of the facility bed-hold policy at the time of transfer for two of two residents reviewed for hospitalizations (Resident 72 and Resident 74). Findings include: Clinical record review for Resident 72 revealed nursing documentation dated August 16, 2026, 1:21 PM, Resident 72 was found on the floor, and order was given to send her to ED (emergency department). There was no documented evidence that the resident received a written notification of transfer and bed hold information, and that it was only provided to the responsible party. Clinical record review for Resident 74 revealed nursing documentation dated July 2, 2026, at 2:39 PM an order was received to send the resident to the hospital to be evaluated for respiratory distress. There was no evidence Resident 74 received a written notice of transfer and bed hold information at the time of transfer and that the information was only provided to the responsible party. Interview with the Nursing Home Administrator on August 27, 2026, at 11:15 AM, confirmed that the facility did not provide Resident 72 and Resident 74 with copies of written transfer or bed-hold notices as noted above. 28 Pa. Code 201.14(a) Responsibility of license

Plan of Correction - To be completed: 10/12/2026

1. Resident 74 discharged from the facility 7/2/2026. Resident 72 returned from hospital and remains in the facility. Unable to retroactively correct the Notice of transfer and bed hold.

2. Residents being transferred out of facility to the hospital have the potential to be affected.

3. Nursing Home Administrator or designee will educate licensed nursing staff on policy and procedure for completing and sending a notice of transfer and bed hold with all residents going to the hospital. Nursing Home Administer will educate the Social Service department on the procedure for sending a copy of the signed notice of transfer and bed hold policy to both the RP and resident, and to document in a progress note when the letter and copies were sent.

4. Nursing Home Administrator or designee will audit all transfers Weekly x 4 weeks, then monthly x 2 month to ensure appropriate bed hold and transfer notices were provided to appropriate parties as required. Tracking and trending will be reviewed through the Quality Assurance Performance Improvement Committee for recommendations.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations: Based on clinical record review, review of facility documentation, and resident and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan for an implanted medical device and a PICC (peripherally inserted central catheter) for one of 17 residents reviewed (Resident 4). Findings include: Clinical record review for Resident 4 revealed a diagnosis list that included the presence of an automatic implantable cardiac defibrillator (an electronic device to help regulate the beating of the heart and can deliver an electrical shock to restore a normal heartbeat), atrial fibrillation (an irregular heart rhythm), and sudden cardiac arrest. Nursing documentation for Resident 4 dated July 24, 2026, at 1:39 PM revealed the resident was admitted to the facility and has a pacemaker. Hospital documentation for Resident 4 dated July 13, 2026, at 8:44 PM noted the resident has an ICD (implantable cardiac defibrillator). An interview with Resident 4 on August 25, 2026, at 11:53 AM revealed that the resident reported an implanted cardiac "defibrillator." Review of Resident 4's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's device, any pertinent assessments and/or clinical care concerns related to the device, or any associated precautions. The care plan related to Resident 4's implanted device was requested during a meeting with the Nursing Home Administrator and Interim Director of Nursing on August 25, 2026, at 2:15 PM. The facility provided an updated care plan (after surveyor questioning) to include that Resident 4 has a pacemaker and to test per orders. Observation during the interview with Resident 4 on August 25, 2026, at 11:53 AM revealed that the resident also has a peripherally inserted central catheter (PICC; a thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) in the right arm. The resident reported the PICC was for antibiotics due to an infection. Further review of Resident 4's clinical record revealed an order dated July 28, 2026, for a single lumen power PICC in the right upper arm. There was also an order dated July 24, 2026, at 9:00 PM for an antibiotic to be administered two times a day intravenously (IV, administered into a vein). Review of Resident 4's care plan revealed that the resident is on antibiotic therapy. An intervention dated July 24, 2026, instructed staff to maintain the PICC line as ordered. There was no comprehensive, person-centered care plan that addressed the resident's PICC such as any pertinent assessments and/or clinical care concerns related to the device (assessment of the device or monitoring for any complications such as edema, catheter migration, or infection), or any associated precautions/restrictions. The care plan related to Resident 4's PICC was requested during a meeting with the Nursing Home Administrator and Interim Director of Nursing on August 26, 2026, at 2:15 PM. There was no additional information in the care plan provided by the facility. The facility failed to implement a comprehensive, person-centered, care plan for Resident 4 related to the implanted device and PICC. The Nursing Home Administrator was informed of the concerns with Resident 4's care plan on August 27, 2026, at 11:38 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 10/12/2026

1. Resident 4's pacemaker CP was updated 8/25/2026. Resident 4 discharged from facility. Unable to retroactively correct the comprehensive care plan.

2. Unit managers or designee will conduct a facility wide audit to identify residents with PICC lines and/or pacemakers/defibrillators to ensure a comprehensive care plan is in place.

3. Nursing Home administrator educated licensed nursing staff and interdisciplinary team on writing and implementing a comprehensive care plan for residents with PICC lines and/or defibrillators/pacemakers.

4. The MDS coordinator or designee will audit all new admissions weekly x 4 weeks, then 5 new admissions monthly x 2 months for comprehensive care plans. Tracking and trending will be reviewed through the Quality Assurance Performance Improvement Committee for recommendations.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations: Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding medication parameters for one of 17 residents reviewed (Resident 15) and failed to ensure the availability of necessary emergency supplies as per the physician order for one out of one resident reviewed with a PICC (Resident 4). Findings include: An interview and subsequent observation with Resident 4 on August 25, 2026, at 11:53 AM revealed that the resident currently has a peripherally inserted central catheter (PICC; a thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) in the right arm. The resident reported the PICC was for antibiotics due to an infection. Review of Resident 4's clinical record revealed an order dated July 28, 2026, for a single lumen power PICC in the right upper arm. There was also an order dated July 24, 2026, at 9:00 PM for an antibiotic to be administered two times a day intravenously (IV, administered into a vein). Further review of Resident 4's clinical record revealed a physician order dated July 24, 2026, for a pressure dressing and hemostats at bedside. During the medication pass observation on August 26, 2026, at 12:58 PM with Employee 6, licensed practical nurse, the staff member reported the pressure dressing and hemostats should be located on the IV pole in the resident's room. Employee 6 was unable to locate the pressure dressing or hemostats at the bedside. Employee 6 proceeded to check the medication cart in the hallway outside of the resident's room and also the locked medication/staff room on the unit across from the dining room area and was not able to locate the pressure dressing and hemostats at that time. A later interview with Employee 6 on August 26, 2026, at 1:36 PM revealed that the staff member had found the bag with the pressure dressing and hemostats in the "other cart." The above information was reviewed during the meeting on August 26, 2026, at 2:15 PM with the Nursing Home Administrator and interim Director of Nursing. The facility failed to ensure the availability of necessary emergency supplies at bedside as per the physician order. Clinical record review for Resident 15 revealed a diagnosis list that included essential (primary) hypertension (high blood pressure) Clinical record review for Resident 15 revealed a current physician order dated December 15, 2025, at 8:00 AM for Losartan Potassium (a medication that lowers the blood pressure) give 25 milligrams (mg) by mouth one time a day for essential (primary) hypertension. The order noted to hold the medication for a systolic blood pressure (SBP; the top number of a blood pressure reading where the heart contracts) less than 120. Further review of the physician orders for Resident 15 revealed a current physician order dated December 15, 2025, a t 8:00 AM for Metoprolol Succinate ER (extended release) 24-hour (a medication that is used to treat high blood pressure and/or heart rate); give 50 mg by mouth one time a day related to essential (primary) hypertension. The order noted to hold the medication for a systolic blood pressure less than 100 or a heartrate less than 60. A review of the Medication Administration Record (MAR) for Resident 15 for July and August 2026 revealed that the Losartan was marked as administered outside of the physician specified parameters for the following dates: July 6, 2026; blood pressure was documented as 119/85. August 3, 2026; blood pressure was documented as 108/57 August 6, 2026; blood pressure was documented as 114/74 A review of the MAR for Resident 15 for July and August 2026 revealed that the Metoprolol was marked as administered outside of the physician specified parameters for the following dates: July 27, 2026; pulse documented as 58. There was no documentation for Resident 15 to indicate a rationale for why the medication was administered outside of the specific stated parameters. The Nursing Home Administrator was advised of the findings on August 27, 2026, at 9:08 AM. An interview with Employee 5, registered nurse, on August 27, 2026, at 11:55 AM confirmed that the medications were given outside of the physician ordered parameters. 483.25 Quality of Care Previously Cited 9/26/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 10/12/2026

1. Resident 4 has discharged from the facility. The Emergency kit which included a pressure dressing and hemostats at bedside was placed at the bedside affixed to the IV pole immediately upon notice it was missing for resident4.

1.Resident 15 was assessed with no adverse effects related to blood pressure medication administered outside of parameters. CRNP was notified of blood pressure medication administered outside of parameters with no new orders received.

2.DON or designee will conduct a facility wide audit of current residents to identify any residents with PICC lines to ensure emergency kits are at the bedside.

2. DON or designee will conduct a facility wide audit for current residents with blood pressure medications with parameters and contact CRNP for review and clinical recommendations if parameters continue to be appropriate. A 1-week retrospective audit will be conducted on those residents with blood pressure medications to ensure they have been administered as ordered within established parameters with appropriate assessment and follow up for any residents identified as having received blood pressure medication outside of ordered parameters.

3.Director of Nursing or designee will educate licensed nursing staff on Ftag 0684 and the importance of ensuring emergency kits are at the bedside for any resident with PICC lines.

3.DON or designee will educate licensed nursing staff on Ftag 0684 and the importance of ensuring blood pressure medications are administered as ordered following established parameters for administration.

4.Director of Nursing or designee will audit all residents with PICC lines to ensure emergency kits are at the bedside. Audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for review and recommendations.

4.DON or designee will conduct a random sample audit of 5 residents on blood pressure medications with parameters to ensure these medications are being administered as ordered and within set parameters. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for review and recommendations.

§483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

§483.35 Nursing Services

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.

The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations: Based on review of facility documentation, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with medication, indwelling catheter care, wound care, and tube feeding for two of three employees reviewed (Employees 7 and 8). Findings include: A review of the facility Resident Matrix (CMS-802, form used to identify pertinent care categories for residents who reside in the facility) revealed that the facility had a total of six residents with indwelling urinary catheters and at least one resident with tube feedings. A review of sampled residents of the current resident population revealed that the facility had multiple residents that received medications and had various wounds. A review of the Facility Assessment noted a section for staff competencies. The competencies for registered nurse and licensed practical nurse staff included (in part): medication administration, catheterization/foley catheter care, wound care / VAC (vacuum-assisted closure) dressing, and tube feeding. A request by the surveyor for staff competencies that included medication administration, catheterization/catheter care, wound care, and tube feeding was made for Employee 7 (registered nurse). Competencies that included wound care, medication administration, and tube feeding were also requested for Employee 8 (licensed practical nurse). These competencies were requested during a meeting with the facility on August 26, 2026, at 2:15 PM and again on August 27, 2026, at 11:13 AM. Facility documentation titled "LVN/RN Skills Competency Checklist" dated June 20, 2026, for Employee 7, noted a checklist with various nursing skills. The document further noted to, "Please rate your skill level by checking the appropriate box using the key below." However, there was no noted evaluator assessment or competencies associated with the skills listed in the document and the document was noted to be self-rated. The facility provided a skills fair sign-in dated January 20, 2026, however Employee 7's and Employee 8's signatures were not noted on the sign-in sheet as having attended. The facility provided no competency evaluations or associated documented competency demonstrations that were noted for Employee 7 and Employee 8. An interview with the Nursing Home Administrator on August 27, 2026, at 1:00 PM revealed the facility was unable to produce any further documentation that the above employees had completed competency evaluations in the areas requested. 483.35 Nursing Services Previously cited deficiency 9/26/25 28 Pa Code 201.20(a)(6)(d) Staff development

Plan of Correction - To be completed: 10/12/2026

1. Employees 7 and 8 will receive the required education/training prior to their next scheduled shifts in the facility.

2. The DON or designee will review assignment sheets for the dates 8/30/2026 – 9/9/13/2026 to ensure all scheduled agency personnel have a completed competency packet.

3. Current Agency personnel competency packets reviewed and revised. The Nursing Home administrator will educate licensed nursing staff on new agency packets and process for completion. NHA will also educated house supervisors of need to make sure any agency personnel working on their shift has a completed packet, and if not, provide them with one.

4 The Unit manager or designee will audit 3 agency personnel documentation weekly x 4 weeks then s monthly x2 months to ensure a competency packet has been reviewed and signed, Tracking and trending will be reviewed through the Quality Assurance performance Improvement Committee for review and recommendations.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Observations: 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 two of four residents reviewed (Residents 40 and 69). Findings include: Clinical record review for Resident 40 revealed the facility admitted her on February 5, 2026, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 40's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated February 11, 2026, indicated that the facility assessed Resident 40 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 40's care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) 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. Clinical record review for Resident 69 revealed a current medical diagnosis list including dementia. Further review revealed that their annual MDS, completed on May 8, 2026, indicated the resident was assessed as having dementia and that a care plan for dementia and cognitive loss would be developed. Review of Resident 69's care plan under "impaired cognitive function/dementia or impaired thought processes related to dementia" revealed general basic interventions such as anticipating resident needs, asking yes/no questions, and keep routine consistent. There was no indication that the facility had implemented an individualized person-centered care plan to address the residents' specific dementia and cognitive loss needs. Interview with Employee 4 (social services) on August 27, 2026, at 10:18 AM confirmed the above findings for Residents 40 and 69. The findings were reviewed with the Nursing Home Administrator on August 27, 2026, at 11:50 AM. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 10/12/2026

1. Residents 40's cognitive/dementia care plan was written 2/11/2026. Individualization to the care plan was completed on 9/4/2026. Resident 69s cognitive/dementia care plan was individualized on 9/4/2026.

2. The Social Service Manager or designee will audit residents with a dementia diagnosis to ensure their care plans have individualized interventions to meet their dementia care needs.

3. The Nursing Home Administrator will educate members of the interdisciplinary team on the importance of individualizing care plans for residents with dementia diagnosis.

4. The RNAC or designee will audit 2 admissions a week x 4 weeks, then 5 per month for 2 months to ensure dementia care plans are individualized to the resident. Tracking and trending will be reviewed through the Quality Assurance performance Improvement Committee for review and recommendations.

§ 201.18(b)(2) LICENSURE Management.:

(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.

Observations: Based on closed clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure accurate documentation regarding the disposition of a resident's personal belongings for two of three closed records reviewed (Residents 2 and 74). Findings include: Closed clinical record review revealed the facility admitted Resident 2 on July 27, 2026. Nursing documentation dated August 18, 2026, at 4:43 AM revealed Resident 2 expired at 2:25 AM. Documentation revealed Resident 2 was wearing a cotton top and a yellow band on her ring finger when removed from the facility. The nursing documentation revealed Resident 2's family did not want any particular belongings to go with her but decided they would pick up the remaining belongings. Review of Resident 2's Inventory of Personal Effects revealed Resident 2's belongings documented on the sheet were not signed as received on discharge/death. Interview with the Nursing Home Administrator on August 26, 2026, at 2:20 PM confirmed the above findings for Resident 2, and was unable to provide any further documentation of the disposition of Resident 2's belonging on discharge. Closed clinical record review revealed the facility admitted Resident 74 initially on May 29, 2026, and again on July 2, 2026. The resident was sent back out to the hospital on July 2, 2026, and subsequently discharged from the facility on the same date. Review of Resident 74's progress notes revealed a phone call had been placed on July 6, 2026, to resident's responsible party in which a voicemail message was left indicating resident's belongings were in the reception closet. There was no evidence of any further follow up on Resident 74's belongings. Interview with the Nursing Home Administrator on August 27, 2026, at 11:15 AM confirmed that the facility could not provide any further documentation that Resident 74 or resident 74's representative had received the resident's belongings or that follow up occurred regarding the disposition of the resident's belongings.

Plan of Correction - To be completed: 10/12/2026

1. Resident 2 passed away 8/18/2026 and resident 74 discharged facility on 7/2/2026. Unable to retroactively correct resident personal belongings disposition documentation.

2. Residents discharging from the facility have the potential to be affected by the deficient practice.

3. Nursing Home Admiinistrator or designee will educate nursing staff responsible for completing resident discharges on the importance of obtaining signatures on personal belongings sheet when the resident/RP retrieve personal belongings from the facility upon discharge or death.

4. The DON or designee will audit the personal belongings disposition documentation/forms for 10 who have discharged or expired residents weekly x 4 weeks, then monthly x 2 months. Tracking and trending will be reviewed through the Quality Assurance performance Improvement Committee for revew and recommendations.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations: Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure completion of a discharge summary within 30 days for two of three discharged residents reviewed (Residents 74 and 76). Findings Include: Closed clinical record review for Resident 74 revealed the resident was discharged from the facility on July 2, 2026, after being admitted and transferred to the hospital on the same day. There was no evidence of a discharge summary completed by the resident's physician to include a final diagnosis within 30 days of the resident's discharge. Clinical record review for resident 76 revealed they were admitted on June 12, 2026, and discharged against medical advice on June 18, 2026. Resident 76's closed clinical record did not contain a discharge summary completed by their physician. Additional information related to Resident 76's physician summary of discharge was requested from the facility on August 26, 2026, at 2:30 PM, but none was provided. Interview with the Nursing Home Administrator on August 27, 2026, at 11:15 AM confirmed the above findings for Resident's 74 and 76.

Plan of Correction - To be completed: 10/12/2026

1. Resident 74 discharged from the facility 7/2/2026. Resident 76 discharged 6/18/2026 from the facility. Unable to retroactively correct the discharge summary documentation.

2. Facility Health Information Coordinator will conduct a facility wide audit of residents that have discharged or expired in the last 30 days. Missing discharge summaries/recapitulation of stays will be requested from Physician or Physician extender for any identified as missing.

Nursing Home Administrator or designee will educate facility practicing Physicians and Physician extenders on need for DC summary/recapitulation of stay on all residents.

3. Nursing Home Administrator or designee will educate facility practicing Physicians and Physician extenders on need for DC summary/recapitulation of stay on all residents.

4. Facility Health Information Coordinator or designee will audit all discharges/deaths Weekly x 4 weeks, then monthly x 2 month. Tracking and trending will be reviewed

through the Quality Assurance Performance Improvement Committee for recommendations. .

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