Lewisburg, PA

Buffalo Valley Lutheran Villag

2-star overall rating with 2-star inspections with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

189 East Tressler Boulevard, Lewisburg, PA

(570) 524-2221

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

102

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1975-05-17

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.43

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.30

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.46

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.19

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.73

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.94

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.11

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

4.63

CMS adjusted total nurse staffing hours

Case-mix index

1.24

Higher values indicate more complex resident acuity

RN turnover

86%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

92%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,450

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

39.92

Composite VBP score used to determine payment impact.

Payment multiplier

0.9929

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.64

Baseline 23.39% · Performance 21.39% · Measure score 2.64 · Achievement 0 · Improvement 2.64

Healthcare-associated infections

6.36

Baseline 7.19% · Performance 5.93% · Measure score 6.36 · Achievement 6.36 · Improvement 5.22

Total nurse turnover

3.57

Baseline 52.17% · Performance 49.11% · Measure score 3.57 · Achievement 3.57 · Improvement 0.62

Adjusted total nurse staffing

3.39

Baseline 3.99 hours · Performance 4.04 hours · Measure score 3.39 · Achievement 3.39 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.53%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 256 · Observed rate 8.98% · Lower 95% interval 7.17%
Discharge to community	57%	50.57% 6.4 pts better	Better than the National Rate · Eligible stays 256 · Observed rate 54.69% · Lower 95% interval 51.51%
Medicare spending per beneficiary	0.73	1.02 0.3 pts better
Drug regimen review with follow-up	99.13%	95.27% 3.9 pts better	Numerator 114 · Denominator 115
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 115
Discharge self-care score	35.48%	53.69% 18.2 pts worse	Numerator 33 · Denominator 93
Discharge mobility score	50.54%	50.94% 0.4 pts worse	Numerator 47 · Denominator 93
Pressure ulcers or injuries, new or worsened	3.48%	2.29% 1.2 pts worse	Numerator 4 · Denominator 115 · Adjusted rate 3.36%
Healthcare-associated infections requiring hospitalization	5.93%	7.12% 1.2 pts better	No Different than the National Rate · Eligible stays 121 · Observed rate 3.31% · Lower 95% interval 3.2%
Staff COVID-19 vaccination coverage	0.78%	8.2% 7.4 pts worse	Numerator 1 · Denominator 129
Staff flu vaccination coverage	90.85%	42% 48.8 pts better	Numerator 149 · Denominator 164
Discharge function score	47.31%	56.45% 9.1 pts worse	Numerator 44 · Denominator 93
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient	98.48%	96.28% 2.2 pts better	Numerator 65 · Denominator 66
Resident COVID-19 vaccinations up to date	10.53%	25.2% 14.7 pts worse	Numerator 6 · Denominator 57

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	1.7 0.5 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.7	1.2 0.5 pts better	1.8 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	86.9% 12.1 pts better	93.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 97.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	93.5% 6.5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	1.3%	3.2% 1.9 pts better	3.3% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.3% · Q3 0.0% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.7%	6.5% 5.8 pts better	11.4% 10.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7%
Percentage of long-stay residents who lose too much weight	6.4%	6.5% 0.1 pts better	5.4% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.1% · Q3 5.9% · Q4 4.6% · 4Q avg 6.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.2%	19.9% 6.7 pts better	19.6% 6.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 14.5% · Q3 11.4% · Q4 12.5% · 4Q avg 13.2%
Percentage of long-stay residents who received an antipsychotic medication	21.3%	18.7% 2.6 pts worse	16.7% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 22.8% · Q3 19.7% · Q4 19.7% · 4Q avg 21.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	27.5%	19.6% 7.9 pts worse	16.3% 11.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.1% · Q2 27.5% · Q3 19.2% · Q4 30.6% · 4Q avg 27.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	24.9%	18.3% 6.6 pts worse	14.9% 10 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 27.5% · Q3 15.6% · Q4 32.8% · 4Q avg 24.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	5.0%	1.7% 3.3 pts worse	1.7% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.4% · Q3 5.4% · Q4 4.1% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.3%	26.4% 1.9 pts worse	19.8% 8.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 33.4% · Q3 28.4% · Q4 25.3% · 4Q avg 28.3%
Percentage of long-stay residents with pressure ulcers	7.2%	5.3% 1.9 pts worse	5.1% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.4% · Q3 5.4% · Q4 7.4% · 4Q avg 7.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.8%	68.9% 30.9 pts better	81.7% 18.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.3% · 4Q avg 99.8%
Percentage of short-stay residents who had an outpatient emergency department visit	6.3%	9.8% 3.5 pts better	12.0% 5.7 pts better	Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 6.1% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.4%	68.7% 27.7 pts better	79.7% 16.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.1%	23.1% 2 pts worse	23.9% 1.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 23.5% · Expected 22.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-26 · Fire 2025-09-26

16 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-08-30 · Fire 2024-08-30

10 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-09-01 · Fire 2023-09-01

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-09-26

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-10-24

E · Potential for more than minimal harm 2025-09-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-24

E · Potential for more than minimal harm 2025-09-26

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-10-24

E · Potential for more than minimal harm 2024-08-30

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-09-16

E · Potential for more than minimal harm 2024-08-30

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-09-16

C · Minimal harm 2024-08-30

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2024-09-16

E · Potential for more than minimal harm 2023-09-01

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-11-12

E · Potential for more than minimal harm 2023-09-01

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-11-12

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-26

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-10-29

E · Potential for more than minimal harm 2025-09-26

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2025-10-29

E · Potential for more than minimal harm 2025-09-26

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-09-26

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-09-26

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-09-26

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-09-26

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-09-26

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-09-26

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-09-26

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-09-26

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-09-26

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-10-29

C · Minimal harm 2025-09-26

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-10-29

D · Potential for more than minimal harm 2025-06-12

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-06-12

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-03-21

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-04-15

E · Potential for more than minimal harm 2024-08-30

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-08-30

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-08-30

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-08-30

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-08-30

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-08-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-08-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-08-30

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-08-30

F700 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-08-30

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-10-18

F · Potential for more than minimal harm 2023-09-01

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-01

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-01

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-01

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-01

F700 · Quality of Life and Care Deficiencies

Health

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-01

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-01

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-01

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2023-10-17

B · Minimal harm 2023-09-01

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-10-17

B · Minimal harm 2023-09-01

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2023-10-17

Penalties and ownership

What sits behind the stars

Ownership

Lutheran Senior Services East

5% Or Greater Direct Ownership Interest · Organization

100% 2 facilities 1975-05-17

Feege, Barbara