Health inspection·August 7, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 26 sampled residents. (Resident 7) Findings include:Review of facility policy entitled, Resident Self-Administration of Medication, last reviewed January 20, 2025, revealed that a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The resident's preference will be documented on the appropriate form and placed in the medical record. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form which is placed in the resident's medical record. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the medication cart or medication room.Clinical record review revealed that Resident 7 had diagnoses that included limitation of activities due to disability, [NAME]-Danlos Syndrome (a disease that affects the skin, joints, and blood vessel walls), and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated April 18, 2025, revealed that Resident 7's cognitive ability was intact.Observations on August 5, 2025, at 11:15 a.m., and on August 6, 2025, at 11:40 a.m., revealed that there were two bottles of Fluticasone nasal spray (a medication used to treat symptoms caused by allergies), one bottle of artificial tears, and one bottle of saline nasal spray unsecured on the bedside table in Resident 7's room. Additionally, there was one bottle of gummy vitamins on the shelving next to Resident 7's bed and unsecured in the resident's room during the observation periods.In an interview on August 5, 2025, at 11:10 a.m., Resident 7 stated that she self-administered the medications daily.There was no documentation to indicate that the facility had assessed Resident 7 for the ability to self-administer the Fluticasone nasal spray, artificial tears, saline nasal spray, and gummy vitamins. The medications were not secured in her room.In an interview on August 7, 2025, at 10:45 a.m., the Director of Nursing confirmed that Resident 7 was not assessed to self-administer the medications as per the facility policy.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. Residents Affected - Few Page 1 of 3 395188 395188 08/07/2025 Buckingham Valley Rehabilitation and Nursingcenter 820 Durham Road Buckingham, PA 18912

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to implement a physician's order for one of 26 sampled residents. (Resident 4)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included heart failure, diabetes disease, and chronic kidney disease. A physician's order dated March 25, 2025, directed staff to administer a medication (midodrine hydrochloride) three times a day for hypotension. The medication was to be held if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 120 millimeters of mercury (mm/Hg). Review of Resident 4's medication administration record revealed that staff administered the medication 11 times in June 2025, 17 times in July 2025, and one time in August 2025, when the resident's SBP was greater than 120 mm/Hg. In an interview on August 7, 2025, at 12:15 p.m., the Administrator confirmed that medications were administered outside of the established parameters for Resident 4. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Residents Affected - Few 395188 Page 2 of 3 395188 08/07/2025 Buckingham Valley Rehabilitation and Nursingcenter 820 Durham Road Buckingham, PA 18912

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on facility policy review, facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for one of 26 sampled residents. (Resident 136) Review of facility policy entitled, Admissions, last reviewed January 20, 2025, revealed that the admissions process was intended to include obtaining all the information possible about the resident for the development of the comprehensive care plan, and to assist the resident in becoming comfortable in the facility.A review of facility documentation revealed that Resident 136 arrived at the facility on July 10, 2025, at 6:00 p.m., from the hospital for skilled and rehabilitation services, and was received and signed in by staff at 6:09 p.m. Documentation revealed that at 7:12 p.m., the kiosk recorded the resident left the facility with her husband. There was a lack of documentation in the clinical record to support that staff obtained all the information possible about the resident, including identifying information, during the admissions process.In an interview on August 6, 2025, at 1:25p.m., the Director of Nursing confirmed that Resident 136's clinical record did not contain any information about the resident at admission, including identifying information. 28 Pa. Code 211.5(f) Medical records. 395188 Page 3 of 3