Inspection·August 4, 2023

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review it was determined that the facility failed to ensure that a resident recieved trauma-informed care in accordance with professional standards of practice for one of 26 sampled residents. (Resident 55) Residents Affected - Few Findings include: Clinical record review revealed that Resident 55 had diagnoses that included dementia, recurrent depressive disorder, and PTSD. A review of the psychologist's notes revealed the resident's PTSD was related to experiences related to active military service. Resident 55 was seen in regularly scheduled, semimonthly supportive care visits with psychological services from June 28, 2021, until November 17, 2022. On November 17, 2022, the psychologist recommended a follow up visit within one to two weeks. There was no documentation to support that the resident was seen again for this issue until July 6, 2023. Review of the resident's clinical record revealed that there was no documentation of assessments or trauma-specific interventions to meet the resident's needs for minimizing triggers or additional trauma between November 2022 and July 2023. 28 Pa. Code 211.12(d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395188 If continuation sheet Page 2 of 4 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 395188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Valley Rehabilitation and Nursingcenter 820 Durham Road Buckingham, PA 18912 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 0806 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observations and interviews, review of weekly menus, and clinical record review, it was determined that the facility failed to accommodate each resident's food preferences for four of 26 sampled residents. (Residents 1, 5, 75, 107) Findings include: Review of the lunch menu for Tuesday, August 1, 2023, revealed that baked ham, bread dressing, buttered cabbage, and applesauce were offered for lunch. Alternate choices to the planned meal included turkey sandwich, chicken salad sandwich, and cole slaw. The list of available condiments included tomato, mayonnaise, and ketchup. Review of the menu for breakfast on Thursday, August 3, 2023, revealed that a hard-boiled egg was offered for breakfast. Alternates to the hard-boiled egg included an omelet. Clinical record review revealed that Resident 1 had diagnoses that included chronic kidney disease and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment, dated May 29, 2023, revealed the resident had no cognitive impairment and could clearly communicate. Review of the resident's requested menu items for Tuesday, August 1, 2023, revealed that she requested an alternate menu option of a turkey sandwich, cole slaw, lettuce, tomato, and mayonnaise. The resident was observed eating baked ham, bread dressing, buttered cabbage, and applesauce for lunch on August 1, 2023, at 1:45 p.m. The resident stated this was not the meal that was ordered. Clinical record review revealed that Resident 5 had diagnoses that included esophageal reflux and muscle weakness. Review of the MDS assessment, dated May 7, 2023, revealed the resident had no cognitive impairment and could clearly communicate. Review of the resident's requested menu items for Tuesday, August 1, 2023, revealed that she requested cole slaw, tomato, and ketchup with her meal. The resident was observed eating baked ham, bread dressing, buttered cabbage, and applesauce for lunch on August 1, 2023, at 1:47 p.m. The resident stated this was not the meal that was ordered. Clinical record review revealed that Resident 75 had diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure. Review of the MDS assessment, dated May 22, 2023, revealed the resident had no cognitive impairment and could clearly communicate. Review of the resident's requested menu items for Tuesday, August 1, 2023, revealed that he requested applesauce, a chicken salad sandwich, cole slaw, tomato, and mayonnaise with his meal. The resident was observed eating baked ham, bread dressing, buttered cabbage, and applesauce for lunch on August 1, 2023, at 1:50 p.m. The resident stated this was not the meal that was ordered. Clinical record review revealed that Resident 107 had diagnoses that included dementia. Review of the MDS assessment, dated July 13, 2023, revealed the resident was confused. Review of the resident's meal ticket that accompanied his lunch meal on Tuesday, August 1, 2023, noted he should have received buttered cabbage and applesauce. In an interview on August 1, 2023, at 1:38 p.m., Resident 107's family member stated that the resident did not receive these items on his lunch tray. 28 Pa. Code 201.14(a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395188 If continuation sheet Page 3 of 4 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 395188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Valley Rehabilitation and Nursingcenter 820 Durham Road Buckingham, PA 18912 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and a review of facility documentation, it was determined that the facility failed to maintain resident care equipment in safe operating condition for two of 26 sampled residents. (Residents 43, 75) Residents Affected - Few Findings include: Clinical record review revealed that Resident 43 had diagnoses that included dementia and acute respiratory failure. Resident 43 had an order dated August 2, 2023, that staff provide oxygen via nasal cannula. On August 1, 2023, at 11:15a.m., Resident 43's oxygen concentrator had a heavy buildup of dust on the intake vent. The product manual recommended that the outside of the cabinet should be cleaned every week. In an interview on August 3, 2023, at 9:50 a.m., RN 1 confirmed the oxygen concentrator had a significant accumulation of dust on the vent. Clinical record review revealed that Resident 75 had diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure. Review of the most recent Minimum Data Set assessment, dated May 22, 2023, revealed the resident had no cognitive impairment and could communicate clearly. Resident 75 had an order dated February 28, 2022, that staff provide oxygen via nasal cannula. On August 1, 2023, at 11:00 a.m., the resident was observed receiving oxygen. There was a heavy buildup of dust on the back of the concentrator at the air intake vent. Resident 75 stated in an interview at that time that the machine does not get cleaned. In an interview on August 3, 2023, at 2:15 p.m., the Administrator stated that maintenance was responsible for keeping the outside of the machines clean. 28 Pa. Code 201.18 (b)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395188 If continuation sheet Page 4 of 4