Health inspection·September 1, 2023

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed hold policy to the resident or responsible party for two of six residents reviewed for hospitalizations (Resident 50 and 81). Findings include: Review of Resident 81's clinical record revealed that the facility sent him to the hospital on June 29, 2023. There was no documented evidence in Resident 81's clinical record to indicate that the facility provided him, or his responsible party written information on the facility's bed hold policy. Clinical record review for Resident 50 revealed the resident was sent to the hospital on June 28, 2023, and admitted . There was no evidence to indicate Resident 50's responsible party was provided written information on the facility's bed hold policy. Interview with the Administrator and Director of Nursing on August 31, 2023, at 12:12 PM confirmed the above findings for Resident 81 and 50. 483.15(d) Notice of bed-hold policy and return Previously cited 9/30/22 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 2 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of two residents reviewed (Residents 3 and 32). Residents Affected - Few Findings include: Review of Resident 3's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 10, 2023, indicating that the facility assessed him as being on an antibiotic. Resident 3's MDS dated [DATE], also indicated that the facility assessed him as being on an antibiotic. Review of Resident 3's clinical record revealed no documented evidence of his physician ordering an antibiotic during the lookback time frames for his March 10, 2023, and June 6, 202,3 MDS. Interview with the Administrator and Director of Nursing on August 31, 2023, at 9:32 AM confirmed that Resident 3's MDS's were coded in error for using an antibiotic. Review of Resident 32's clinical record revealed an annual MDS dated [DATE], indicating the facility assessed her as having schizophrenia (a mental illness that is characterized by thoughts or experiences that are out of touch with reality). Interview with the Administrator on August 31, 2023, at 9:26 AM confirmed that Resident 32 did not have a diagnosis of schizophrenia and that when the facility changed to a different electronic medical record that it was added in error. 483.20(g) Accuracy of Assessments Previously cited 9/30/22 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 3 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 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 provide treatment and care for the prevention of skin excoriation for one of one resident reviewed for skin concerns (Resident 23). Residents Affected - Few Findings include: Review of a consultant wound evaluation for Resident 23 dated August 1, 2023, revealed the resident had MASD (MASD, moisture associated skin damage, excoriation of the skin due to prolonged exposure to feces, urine, or perspiration) that measured 0.6 cm (centimeter) x 0.3 cm. The wound was improved as evidenced by the decreased surface area. House barrier cream (protective skin care such as Calmoseptine ointment) was to be applied once daily for 16 days. Review of the TAR (TAR, treatment administration record) for Resident 23 dated August 8 through 21, 2023, revealed that Calmoseptine ointment was applied to the sacrum (low back) area daily for 14 days then the physician indicated to reassess for a new treatment. Review of a consultant wound evaluation for Resident 23 dated August 15, 2023, revealed the consultant signed off from the resident's care as she was on Hospice (health care that focuses on the care of terminally ill residents, that prioritizes comfort and quality of life by reducing pain and suffering). The resident was not seen by the consultant on this date. Review of the TAR for Resident 23 revealed that on August 22, 2023, the resident was reassessed for further treatment of the sacrum if needed. Review of a nursing progress note for Resident 23 dated August 24, 2023, at 2:38 PM revealed the sacral area was assessed and measured as 0.1 cm x 0.1 cm, with no observed drainage or redness. The Calmoseptine treatment was to continue. Review of the August TAR revealed that Calmoseptine was not applied since August 24, 2023. Review of a nursing skin/wound note for Resident 23 dated August 30, 2023, at 8:07 AM revealed documentation of skin issues was labeled by numbers. Skin issue #002, with the right buttocks was 0.1 cm x 0.1 cm. Skin issue #004, with the left buttocks was excoriation. Skin issue #006 buttocks generalized, 0.1 x 0.1. Observation of Resident's 23 sacral area and buttocks on August 31, 2023, at 11:12 AM with Employee 6, licensed practical nurse, revealed the resident had healing MASD as described in the above note. The surveyor asked Employee 6 what treatment was ordered. Employee 6 indicated that there was no treatment ordered and she would be calling the supervisor for a treatment. Interview with Employee 7, nurse aide, on August 31, 2023, at 11:22 AM revealed that she did not apply any treatment to Resident 23's buttocks this date. Review of a skin/wound nursing note dated August 31, 2023, at 11:40 AM revealed that a new order was received from the physician for Calmoseptine ointment to the sacrum, right and left buttocks after cleansing with soap and water and patting dry, every shift until healed. During a meeting with the Nursing Home Administrator and Director of Nursing on August 31, 2023, at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 4 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 0684 2:00 PM it was confirmed that a treatment was not in place for Resident 23's MASD since August 24, 2023. Level of Harm - Minimal harm or potential for actual harm 483.25 Quality of Care Previously cited 1/30/23 and 9/30/22 Residents Affected - Few 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 5 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for two of two residents reviewed for respiratory care (Residents 309 and 310). Residents Affected - Few Findings include: Observation of Resident 309 on August 29, 2023, at 11:28 AM revealed a continuous positive airway pressure (CPAP, a machine used during sleep to keep the airway open) machine in the resident's room. A concurrent interview revealed the resident utilized the CPAP, every night. An opened gallon container of distilled water was also noted. The container did not have an opened date on the bottle. Observation of Resident 309 on August 30, 2023, at 11:24 AM revealed a CPAP mask draped across the top drawer of the resident's bedside dresser. The mask was not bagged or protected from contamination from the ambient environment. The opened container of distilled water still did not have an opened date marked on it. Observation of Resident 309 on August 30, 2023, at 12:28 PM revealed the CPAP mask was still draped across the top drawer of the resident's bedside dresser. The CPAP mask remained unbagged or protected from contamination from the ambient environment. A concurrent interview with Employee 5, licensed practical nurse, confirmed that the container of distilled water was not labeled with an opened date, the CPAP mask should be bagged when not in use, and it was unclear if the CPAP was cleaned. Clinical record review for Resident 309 revealed a care plan dated August 18, 2023, that indicated the resident had a care plan for CPAP / BiPAP Therapy. The interventions included: the resident will adhere to the regimen and staff are to encourage the resident's use of the CPAP / the resident utilizes the CPAP when asleep. The care plan and physician orders did not address the CPAP settings or cleaning instructions for the mask/unit. Clinical record review for Resident 310 revealed the resident was admitted to the facility with a diagnosis list that included pneumothorax (a collapsed lung). A current physician's order for Resident 310 dated August 18, 2023, revealed the resident was to use an incentive spirometer (a handheld breathing device utilized to strengthen the lungs, help prevent infections, and provide respiratory feedback to staff). The order noted the resident was to utilize the incentive spirometer 10 - 15 breaths, making sure to wait several seconds between each breath, every one to two hours during daytime hours. A current care plan for Resident 310 dated August 19, 2023, revealed the resident has an altered respiratory status related to a recent pneumothorax. An intervention noted the resident was to utilize the incentive spirometer per physician orders. Observation of Resident 310 on August 29, 2023, at 12:02 PM revealed there was no incentive spirometer in the resident's room for use. Observation of Resident 310 on August 30, 2023, at 9:27 AM revealed there was no incentive spirometer in the resident's room for use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 6 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of Resident 310 on August 30, 2023, at 10:43 AM revealed there was no incentive spirometer in the resident's room for use. A concurrent interview revealed the resident does not have an incentive spirometer in the room and has not been using one. Further review of Resident 310's clinical record revealed no evidence that the staff were administering the incentive spirometer as ordered by the physician and as indicated by the resident's care plan. An interview with Employee 5 on August 30, 2023, at 10:47 AM regarding Resident 310's incentive spirometer use revealed that the incentive spirometers are, normally kept at bedside if ordered. Upon review of the clinical record, Employee 5 revealed that the resident has not been completing the incentive spirometer because it did not pop in the clinical record for staff to ensure the task was being completed and documented as being performed. The above information for Residents 309 and 310 were reviewed in a meeting on August 30, 2023, at 2:12 PM with the Nursing Home Administrator and Director of Nursing. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 7 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess for risk of side rail entrapment and review the risk and benefits of side rail utilization with the resident or resident representative for two of 11 residents reviewed for accident hazards (Residents 70 and 309). Findings include: Observation of Resident 70 on August 29, 2023, at 2:16 PM revealed the resident's bed had bilateral side rails. A concurrent interview revealed the resident was not aware why the side rails were on the bed, for safety, I think. Clinical record review for Resident 70 revealed no informed consent, assessment for risk of side rail entrapment, or a review of the risks and benefits of side rails with the resident. Documentation for Resident 70 titled Enabler Evaluation, that was dated August 28, 2023, at 1:37 PM revealed an evaluation form that noted that side rail replacement recommendations were marked as none, and side rail placement was documented as Side Rails / Assist Bar are not indicated at this time. Observation of Resident 309 on August 29, 2023, at 11:33 AM revealed that the resident had a side rail attached to the resident's left side of the bed. Clinical record review for Resident 309 revealed no informed consent, assessment for risk of side rail entrapment, or a review of the risks and benefits of side rails with the resident. Documentation for Resident 309 titled Enabler Evaluation, that was dated August 21, 2023, at 1:50 PM revealed an evaluation form that noted that side rail replacement recommendations were marked as none, and side rail placement was documented as Side Rails / Assist Bar are not indicated at this time. An interview with the Director of Nursing on August 31, 2023, at 1:55 PM revealed that therapy had assessed both Residents 70 and 309 as not needing the side rails; however, the side rails were still on the beds from previous admissions and should have been removed. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 8 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure nurses demonstrated competency in skills necessary for resident care for three of four staff reviewed for bladder scanning competencies (Employees 1, 2, and 3; Resident 14). Findings include: Review of a physician's order dated June 22, 2022, through July 29. 2023, for Resident 14 revealed the nurse was to perform a bladder scan (a device that measures an approximate volume of urine within the bladder, to determine if the bladder needs emptied when a person cannot empty the bladder to prevent kidney damage and/or infections) every shift and if the amount was greater than 250 ml (milliliters), the nurse was to straight catheterize the resident. If having to straight catheterize the resident frequently, get a urology (a physician who specializes in medical illness related to the urinary tract, i.e., bladder, kidneys, and associated area) appointment. Review of a physician's order dated July 29, 2023, from August 20, 2023, for Resident 14 revealed the nurse was to perform a bladder scan every dayshift and as needed, and if the amount was 350 ml, the nurse was to straight catheterize (a short-term insertion of a tube into the bladder to drain urine) the resident. If having to straight catheterize three times or more in one week, place a Foley urinary catheter (a type of indwelling catheter, a flexible tube placed in the bladder that is connected to a bag to drain urine from the bladder). Review the MAR (MAR, record for documenting medication administration) for Resident 14 during June 2023 revealed that Employee 1, LPN (licensed practical nurse) performed bladder scanning. Review of the MAR for Resident 14 during June and July 2023, revealed Employees 1 and 2, LPN, performed bladder scanning. Review of the MAR for Resident 14 during August 2023, revealed that Employee 3, LPN, performed bladder scanning. Review of the facility's documentation for Employees 1, 2, and 3 revealed that there was no evidence that the LPNs had been assessed for bladder scanning competencies (proof of ability to perform the task successfully). During a meeting with the Nursing Home Administrator on August 31, 2023, at 2:00 PM it was confirmed that bladder scanning competencies were not competed for LPNs hired through an agency. 28 Pa Code 201.20(a)(6)(b)(d) Staff development FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 9 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, it was determined that the facility failed to post at the beginning of each shift the nurse staffing information in a prominent place readily accessible to residents and visitors. Residents Affected - Some Findings include: Observation of the facility's main entrance on August 29, 2023, at 9:06 AM revealed the current posting of nurse staffing information that included the facility name, current date, total number, and the actual hours worked by licensed and unlicensed nursing staff, and the resident census was dated August 23, 2023. During an interview with the Employee 8, Executive Director, on August 29, 2023, at 10:01 AM the surveyor asked for the nurse staff posting information for the past 30 days. There was no staffing information from August 24 through August 28, 2023. The staffing sheet for August 29, 2023, was provided for after the surveyor asked. The surveyor reviewed the above findings with the Nursing Home Administrator on August 30, 2023, at 2:00 PM. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(d)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 10 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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. Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regimen was free from potentially unnecessary medications for one of five residents reviewed (Resident 14). Findings include: Clinical record review for Resident 14 revealed the resident had a diagnosis of unspecified dementia without behavioral disturbance, psychotic (out of touch with reality) disturbance, mood disturbance, and anxiety. Review of a physician's order for Resident 14 dated July 20, 2023, revealed the nurse was to administer lorazepam (a controlled substance prescribed for anxiety) 1 mg (milligram), give 0.25 tablet orally two times a day for agitation and anxiety and 0.25 tablet every six hours as needed for agitation and anxiety. Review of the August MAR (MAR, medication administration record) for Resident 14 revealed the resident received as needed Ativan (brand name for lorazepam) on August 3, 5, 6, 8, 9, 10, 11, and 15, 2023. Clinical record review for Resident's 14 revealed there was no physician's order limiting the timeframe of the as needed Lorazepam to 14 days or documented rationale to indicate the continued use and duration of the as needed medication. During an interview with the Nursing Home Administrator on August 31, 2023, at 2:00 PM the findings for Resident 14 were acknowledged. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 11 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and resident family and staff interview, it was determined that the facility failed to arrange for routine dental care to the extent covered under the State plan for one of two residents reviewed for dental concerns (Resident 50). Residents Affected - Few Findings include: Clinical record review for Resident 50 revealed the resident was admitted to the facility on [DATE]. An observation of Resident 50 on August 29, 2023, at 11:40 AM revealed the resident had natural teeth and some buildup was observed on the resident's teeth. A family member present in Resident 50's room at the time of the observation indicated she was not aware of the resident being offered or receiving dental services since he was admitted to the facility. The family member noticed the resident needed a dental cleaning, and indicated the resident was always very good about receiving dental care routinely prior to residing at the facility. Further clinical record review for Resident 50 did not reveal any evidence the resident was offered or received dental services since his admission to the facility nearly one year ago. An interview with the Nursing Home Administrator and Director of Nursing on August 31, 2023, at 9:23 AM confirmed there was no evidence of Resident 50 being offered or receiving dental services since his admission to the facility for routine dental services at least every six months as the State plan allows. In a follow up interview with the Director of Nursing on August 31, 2023, at 12:00 PM, the Director of Nursing indicated contact had since been made with the family who consented to dental service for the resident and the resident was now scheduled to receive services on September 18, 2023. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.16(a) Social services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 12 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store and prepare food in a safe and sanitary environment in the facility's main kitchen. Residents Affected - Many Findings include: Observation of the facility's main kitchen on August 29, 2023, at 10:05 AM with Employee 4, chef, revealed the following: A foot pedal garbage inside the entrance of the kitchen to the preparation area was covered in dried debris and dried food splatter on the exterior of the can. The exterior door and sides of an upright ice cream freezer contained dried food and food splatter. The backsplash of the stove was observed covered with dried food splatter, which extended to the walls behind the stove area, the sides of the stove, and the lower shelf of a preparation table to the left of the stove. Two kettle units to the right of the stove were observed with dried food on the sides of the kettle, back, and sides of the base of the kettle stand. The tilt kettle was observed with dried food on the sides and back of the tilt kettle. The flooring under the stove, kettles, and tilt kettle had visible debris and dried food under the equipment with significant buildup along the wall edges. A wall mounted knife rack beside the cooking equipment mentioned above was covered in dust and dried food, with a large dried brown substance splattered on the front of it. A metal rolling storage unit storing cans of food sat next to a metal rolling bakers rack in the corner of the kitchen. Papers and debris were observed on the flooring under them extending to where the floor meets the wall. Three pans of canned peaches were observed in an upright two-door cooler. The pans of peaches did not contain any evidence as to when they were opened and placed in the pans or when they needed to be used by. The interior base of the cooler contained multiple colors of dried liquid spills. A lower shelf of a preparation table of the raw meat sink area contained dust and dried splatter. A clear plastic container with a white powdery substance in it was observed on the tabletop next to the sink noted above. The container was labeled as thickener. A white plastic scoop was observed inside the container under the lid, pushed down into the product. The handle of the scoop contained dark colored debris. The lower shelf of an additional preparation table where cutting boards were stored was soiled with dried dust and dried splatter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 13 of 14 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 395261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buffalo Valley Lutheran Villag 189 East Tressler Boulevard Lewisburg, PA 17837 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 0812 Level of Harm - Minimal harm or potential for actual harm The walk-in cooler was observed with multiple open wire rack shelving units with food items stored on the bottom racks six inches from the floor. There was no barrier to protect the food items from the potential contamination from mop water splash or sweeping debris. The lower racks of food storage shelving in the dry storage room contained a buildup of dust and debris. Residents Affected - Many The wall surrounding the entrance to the dish/pan washing area was covered in dried red colored splatter. Employee 4, chef, asked a food service worker nearby if it, was Jell-O from the day before, and the worker stated, maybe. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on August 31, 2023, at 2:15 PM. 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 14 of 14