Health inspection·March 21, 2025

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Resident 1's husband on March 21, 2025, at 12:17 PM revealed that facility staff made him aware of an incident when staff tied Resident 1 to her wheelchair with a shawl from her room. Resident 1's husband stated that he was aware of his wife's behaviors of constantly trying to stand up and down repeatedly and, wanting to go all the time. Clinical record review for Resident 1 did not include evidence of a physician's order or plan of care for the use of a mechanical restraint. Review of a facility investigation dated February 12, 2025, at 12:00 AM revealed that a nurse aide reported to the registered nurse supervisor that a nurse on the unit tied a resident to a wheelchair with a shawl. Information pertinent to the investigation included that Resident 1 was noncompliant with her transfer status, and she had behaviors of frequently placing herself on the floor. A witness statement dated February 11, 2025, obtained from Employee 1 (registered nurse) during the investigation confirmed that Employee 1 took the ends of Resident 1's shawl, wrapped them around the back of her wheelchair, and loosely tied them together. A witness statement dated February 11, 2025, obtained from Employee 4 (nurse aide) during the investigation indicated that Resident 1 stands and tries to sit on the floor anytime a staff member looks away from her, and she had fallen in the beginning of the shift. Resident 1 kept getting up and trying to sit on the floor. Employee 1 took Resident 1 to her room and when she came out of the room, Employee 1 showed Employee 4 that she had a blanket on Resident 1's lap that was tied around the back of the chair. Another nurse aide on the unit, Employee 3, identified the device as a restraint and untied the device. Employee 1 retied the device and Employee 3 made Employee 2 (registered nurse supervisor) aware of the device use when Employee 2 entered the unit around the time of the supper meal. After the supper meal, Employee 4 noted that the blanket was back and twisted around (Resident 1). Employee 4 heard Resident 1 state that she was stuck while trying to stand. Employee 4 stated that Employee 1 admitted to retying the blanket. Employee 4 reported the repeated use of the tied blanket to Employee 2. A witness statement dated February 11, 2025, obtained from Employee 3 confirmed that she untied the blanket on Resident 1's lap, but Employee 1 tied it around Resident 1 again. Employee 3 notified her supervisor (Employee 2), who came to the unit at supper time, and the blanket was removed from Resident 1; however, after Employee 2 left the unit, Employee 1 tied the blanket behind Resident 1's wheelchair again. Employee 3 notified Employee 2 of the repeated use of the device that tied Resident 1 to her wheelchair. A witness statement dated February 11, 2025, obtained from Employee 2 confirmed that she removed a checkered shawl that was on Resident 1's lap and tied around the back of her wheelchair. Employee 2's statement was that she educated Employee 1 against the use of the device that was restricting Resident 1's movement and Employee 1 untied the shawl. An hour later, Employee 2 observed Resident 1 with the shawl around her waist and tied behind the wheelchair. Employee 2 untied the shawl and took Resident 1 with her to her office. Employee 2's statement was that she informed Employee 1 that it was not okay to use restraints and Resident 1's shawl in a restraining manner. The information available from the facility's investigation indicated that supervisory staff noted Employee 1 inappropriately restrained Resident 1 in her wheelchair; however, did not suspend Employee 1 immediately to not permit her on the premises until an investigation was completed. Employee 1 could utilize the inappropriate restraint a second time on Resident 1 and had the potential to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395261 If continuation sheet Page 2 of 3 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 03/21/2025 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 0604 inappropriately restrain other residents assigned to her care. Level of Harm - Minimal harm or potential for actual harm Interview with the Nursing Home Administrator and the Director of Nursing on March 21, 2025, at 3:45 PM confirmed that the facility had no evidence that Employee 2 was counseled regarding permitting Employee 1 on the premises after a known allegation of inappropriate restraint use while the facility completed an investigation. The facility also had no evidence of education provided to all staff after the incident to reinforce the facility's policies regarding restraint use and the protection of residents (via immediate suspension of alleged perpetrators) during abuse investigations. Residents Affected - Few 28 Pa. Code 211.8(c.1)(2)(3)(d) Use of restraints 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 3 of 3